Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Palsy.
Treatment: Aquatherapy/exercise.
The health plan denied Aquatherapy/exercise.
The determination is overturned.

The patient has spastic quadriplegic cerebral palsy (CP) with documented contractures, difficulty controlling upper extremities and dystonia. His movement specialist neurologist documented the importance of at least 2 times (x)/week therapies for their habilitative nature for him to keep him moving. His aqua therapy notes demonstrate how excited he is during aqua therapy and the areas he works on including core and head strength, stretching, range of motion (ROM) and use of extremities. At issue is the medical necessity of aquatic therapy/exercises x12 (4 units for each service date).

The requested health service/treatment of aquatic therapy/exercises x 12 is medically necessary for this patient as detailed above. It is extensively documented in peer reviewed literature how beneficial aquatic therapy is for patients with cerebral palsy. "Exercise in water appeals to children with CP because of the unique quality of buoyancy of water that reduces joint loading and impact, and decreases the negative influences of poor balance and poor postural control.(1) "Aquatic therapy is effective in supporting walking, balance, emotional status and health-related quality of life, spasticity, and physiological indicators. In comparison with land-based interventions, aquatic therapy shows superior effectiveness on balance, walking, muscular strength, proprioception, health-related quality of life, physiological indicators, and cardiorespiratory fitness." (5) Results indicate that the pediatric aquatic therapy group had greater average 66-item Gross Motor Function Measure following intervention than the control group...Pediatric aquatic therapy can be an effective and alternative therapy for children with cerebral palsy even with poor Gross Motor Function Classification System level. (4)
Documentation in the physician letter of medical necessity as well as each physical therapy note document multiple areas of broadly accepted serial objective measures for the patient. Physician notes documents need for habilitative services focusing on range of motion and endurance. Each physical therapy note documents working on range of motion- specifically upper extremity and lower extremity range of motion. Notes further include examples of activities the patient is doing in therapy and that he is improving endurance with those activities. Specific goals for strength and mobility, for example ambulation 10 feet with heavy weights and large noodle is noted in multiple physical therapy notes and then noted as mastered in the 8/24 note. There is extensive documentation working to address Asymmetrical Tonic Neck Reflex (ATNR) reflex and improve grasp and head turning. Different activities are noted to address this throughout the physical therapy sessions, and improving endurance and length of time and improved time until ATNR are documented for patient as well. Further, there is documentation throughout the physical therapy notes documenting activities working on strengthening and midline orientation including head and trunk lifting while using a large noodle, and progress in endurance as well as orientation to midline with these exercises is documented. While there are not any specific tests performed, there is thorough documentation of the broadly accepted serial objective measures documented in all the physical therapy notes, including the noted range of motion, strength and endurance.