Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lack of coordination, muscle weakness 
Treatment: Occupational therapy services 

The insurer denied coverage for occupation therapy services. The denial is upheld. 

This case involves then female child who has a history of intrauterine growth restriction and was born with the umbilical cord wrapped around her left forearm. The patient has been diagnosed with unspecified lack of coordination as well as muscle weakness, unspecified disorder vestibular function and visuospatial defect. The patient attended physical and occupational therapy services and there are no documented issues with her participation. The documentation provided noted that the patient was riding cinches with much effort. Perceptual for handwriting was documented as difficulty staying in the lines. The patient was following midline activity letters much better and was standing but had to do sitting first to isolate head movement. The patient continued to participate in services where she was beginning to color. She was completing strength exercises with less arching of her back. 

Based on the review of the medical record, occupational therapy was initiated with Beery VMI score of 32nd percentile, visual perception in 27th percentile, and motor coordination in the 3rd percentile. These are considered low average and low compared to age normal controls. Sensory testing at that time identified typical scores for social participation, vision, and hearing. The patient had some problems with touch and smell, balance, and motion, planning and ideas, and definite dysfunction in body awareness. The patient's muscle tone and motor coordination were impaired; saccadic eye movements were appreciated. Re-evaluation notes that the patient has been progressing in occupational therapy. The patient had a significant deficit in vestibular discrimination associated with poor attention and stabilizing her eyes during visual pursuit. A plan of care with long-term goals was established, with intent to complete twice a week occupational therapy. Duration was not provided. Upon another re-evaluation it was noted the patient had not participated in occupational therapy due to COVID-19 restrictions. The patient continued to score below average on the Beery VMI and was below average on the WOLD sentence copy test. The patient made significant improvement in area of visual discrimination and scored average in that area. The patient continued to demonstrate deficits in balance skills. A reduced occupational therapy schedule of 1x/week was recommended. Once again, duration was not provided. The progress notes demonstrated good participation in therapies. The documentation does not provide evidence of a home exercise program. 

This patient has a history of developmental delay associated with vestibular dysfunction and farsightedness. It is unclear if the patient wears glasses, but assuming the farsightedness is not improved with lens or contact, the predominant use of the occupational therapy is for vestibular dysfunction. The patient has made slow improvements in motor planning and visual discrimination, but no objective data was provided. The patient remained below average on the Beery VMI. There was no documentation of a home exercise program, parent training, or indication for transition of care to home setting, or documentation that these modalities are contraindicated. The patient has shown improvement in her visual discrimination, but if she did not receive therapies during COVID restrictions, it is presumed that its improvement is due to home program. Therefore, the DOS in question are not considered medically necessary. In fact, these DOS are more congruent with maintenance therapy as no objective progress was indicated. 

The health plan acted reasonably with sound medical judgment, and in the best judgment of the patient. 

Based on the above, the medical necessity for the occupational therapy services provided were not substantiated. The insurer's denial should be upheld.