Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for a Rifton standing machine.Findings:  The physician reviewer found that  the enrollee has a diagnosis of hypotonia leading to significant developmental delay. He has been receiving outpatient physical therapy (PT) services with focus on improving overall functional mobility, strength, balance, and development of motor skills. In addition to PT services, he also receives occupational therapy (OT) and speech therapy (ST). He is currently utilizing bilateral supra-malleolar orthosis (SMOs), is non-ambulatory, has no independent mode of mobility, and is dependent for many activities of daily living and mobility skills. The enrollee has decreased muscle strength and low tone throughout his extremities and his trunk. He demonstrates rolling skills. However, he has poor endurance with activity. He is able to stand with moderate assistance at a support surface for short periods of time, but demonstrates poor alignment secondary to poor muscle tone. He has poor mid-range control, and relies on knee hyperextension and postural fixing for stability. He is demonstrating improved sitting balance, but continues to rely on external support or support from his upper extremities to maintain balance. Because of his poor postural control and reliance of upper extremities for support, the enrollee has limited opportunities for upright posture while simultaneously using his upper extremities to explore and interact with his environment. The dynamic stander was prescribed for upright posture, prolonged stretch of hips/knees, positioning of spine to help prevent scoliosis, improvement of internal organ functioning, strengthening of arms with ability to move, improve social/emotional growth, and increased endurance.  Early gait training can help a child progress through the typical developmental stages of exploratory movement to locomotion to ambulation. The physical benefits of strength gains, joint range of motion, neuromotor development, and respiratory or cardiovascular benefit, have yet to be fully explored and hold promise for the childs motor and health development. Enabling an infant or toddler to move while upright is not only important for their physical advancements: the cognitive, social and emotional benefits are vital for overall development as well. Early mobility through the appropriate use of a gait trainer can truly be very advantageous, allowing for gains on many levels.  Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: One reviewer is board certified in Physical Medicine and Rehabilitation and Pediatric Rehabilitation Medicine. Two reviewers are board certified in Physical Medicine and Rehabilitation. All three reviewers are actively practicing and are experts 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.