Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for the following: (1) in-person physical therapy service (3 times a week for 1 hour); (2) in-person occupational therapy services (1 time a week for 30 minutes); (3) in-person vision therapy services (1 time a week for 30 minutes); and (4) in-person speech therapy with augmentative and alternative communication (AAC) services (2 times a week for 30 minutes). The submitted documentation supports the medical necessity of a portion the requested services. Medical literature note that the impact of weight-bearing activities appears to be site specific, and a greater frequency of weight-bearing activities is related to greater areal bone mineral density of the lumbar spine in growing girls. Given that the patient has a stander at home, daily standing may be implemented by caregivers at home and school, and current medical literature does not support benefits from additional weekly therapy in this clinical setting. Therefore, in-person physical therapy service (3 times a week for 1 hour), are not medically necessary for the treatment of this patient. Researchers report, Children with neurological disabilities frequently have problems with feeding and swallowing. Such problems have a significant impact on the health and well-being of these children and their families. The primary aims in the rehabilitation of pediatric feeding and swallowing disorders are focused on supporting growth, nutrition and hydration, the development of feeding activities, and ensuring safe swallowing with the aim of preventing choking and aspiration pneumonia. In this clinical setting, occupational therapy services may enable the patients caregivers to learn safe feeding techniques and allow for assessment and therapy of fine motor movements to prepare for a trial of an AAC device. Therefore, in-person occupational therapy services (1 time a week for 30 minutes) are medically necessary for the treatment of this patient. The American Academy of Ophthalmology notes, Other than convergence-insufficiency treatment, scientific evidence does not support the assumption that vision therapy is capable of correcting subtle visual defects, nor does it prove eye exercises or behavioral vision therapy to be effective in direct or indirect treatments for learning disabilities. Detailed review of the literature supporting vision therapy reveals that most of the information is poorly validated because it relies on anecdotes, poorly designed studies, and poorly controlled or uncontrolled studies. Their reported benefits can often be explained by the placebo effect or by the traditional educational remedial techniques with which they are usually combined. There is currently no evidence that children who participate in vision therapy are more responsive to educational instruction than are children who do not participate. Thus, current evidence is of poor scientific quality and does not provide adequate scientific evidence that vision training is a necessary primary or adjunctive therapy. Given the lack of support in current medical literature, the requested vision therapy services are not medically indicated. Therefore, in-person vision therapy services (1 time a week for 30 minutes) are not medically necessary for the treatment of this patient. Researchers note that persons with severe disabilities have the right to communication and access to functioning AAC and other assistive technology services and devices at all times. In this case, while the patient has scored below the first percentile in REEL-3 tests for receptive and expressive language, the submitted documentation does not include an in-person testing and evaluation by an AAC specialist. Therefore, in-person speech therapy with AAC services (2 times a week for 30 minutes) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.