Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Duchenne Muscular Dystrophy.
Treatment: 39 home health physical therapy visits; frequency of 3x (times)/week.

The insurer denied coverage for 39 home health physical therapy visits; frequency of 3x/week.  The denial is upheld. 

The request for 39 therapy sessions was denied and 16 visits were approved.

A final adverse determination indicates the documentation does not support full approval for therapy, at the frequency requested and a similar outcome would be likely with fewer skilled visits. 

A letter of medical necessity completed by patient's doctor reports the patient has diagnoses of Duchenne Muscular Dystrophy (DMD), osteoporosis and cardiac transplant on immunosuppression. Per the provider, the patient is wheelchair bound due to bilateral upper and lower limb weakness and also dependent on assistant for nearly all of his activities of daily living (ADL) that include dressing, toileting, meals, transfers, turning and repositioning and medication administration. The provider believes that patient requires physical therapy (PT) and occupational therapy (OT) at the requested frequency to prevent the patient's current range of motion from worsening.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

The requested home health physical therapy visits and frequency are not considered medically necessary for this patient. 

The clinical documentation, provided for review, support that the patient has a diagnosis of muscular dystrophy and is wheelchair bound. The patient is reported to require assistance with activities of daily living (ADLs) of medication and meal preparation, transfers, toileting, turning and repositioning in bed and in the wheelchair and dressing. According to the provider, the physical therapy (PT) and occupational therapy (OT) is provided at a frequency of three (3) times a week to prevent loss of range of motion (ROM) and to decrease the patient's contractures. However, the medical records do not support that the patient requires skilled therapy care at such a frequency, as requested. The provider does not indicate why the patient would not have comparable success with less visits along with a home-based exercise program. The patient is noted to have use of the upper extremities and has the ability to "operate their power assist wheelchair and can operate small devices and type with their hands."

As such, the need for skilled therapy at 39 visits at three (3) times a week is not medically necessary for this patient as the same outcome can be achieved at a fewer frequency.

"Direct treatment implemented by physical therapists, occupational therapists, and speech-language pathologists, tailored to individual needs, stage of disease, response to therapy, and tolerance, provided across the patient's lifespan...Prevention of contracture and deformity...Daily preventive home stretching 4-6 times per week; regular stretching at ankles, knees, and hips; stretching of wrists, hands, and neck later if indicated by assessment" (Birnkrant, D. J., et al., 2018).

"Muscular dystrophies (MDs) are a category of hereditary illnesses characterized by the gradual malfunction and/or weakening of the skeletal muscles. This disease of the muscles also results in hypotonia and joint contracture, along with raised serum creatine kinase (CK) levels. To prevent complications, continuous physiotherapy is advised for children with muscular dystrophy, which is even asked to perform at home as a home exercise program (HEP). As a result, the home exercise program (HEP) is critical in maintaining the optimal health of children with Duchenne muscular dystrophy (DMD)" (Harjpal, P., et al., 2022).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 39 home health physical therapy visits; frequency of 3x/week is not substantiated.