Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypotonia with continued complaints of muscle weakness and difficulties with activities of daily activities (ADLs), strength, endurance, balance and safety. 

Treatment: Ongoing occupational therapy (OT) services, codes 97110, 97112 and 97530.

The insurer denied coverage for ongoing occupational therapy (OT) services, codes 97110, 97112 and 97530. 

The denial is overturned. 

This patient is a male child with a past medical history (PMH) of hypotonia with continued complaints of muscle weakness and difficulties with activities of daily activities (ADLs), strength, endurance, balance and safety. In therapy, the patient initially required maximal prompting for therapeutic exercises to increase core strength, shoulder stability, balance, motor planning, walking, memory, attention, and fine motor development. Then, he received improvement in self-regulation and managing materials. However, he still had fine motor difficulty. Eventually, he demonstrated improved motor planning, wrist and finger strengthening with moderate prompting. 

Madhok SS, Shabbir N. (2020), "In general, the treatment is supportive and most of the time takes precedence over finding the underlying cause. It is tailored to the symptoms of the infant and may depend on the underlying cause. An interprofessional team approach leads to better outcomes for patients. Rehabilitation, nutritional, and respiratory support must be provided. In cases of central hypotonia other than hypoxic-ischemic encephalopathy, the involvement of a metabolic expert and a geneticist is essential. Occupational, speech, and physical therapy have shown to be beneficial and play a crucial role in maximizing muscle function and also play an important role in preventing secondary anatomic deformities. Nutritional support is very important in these patients as they are often underweight and have various macro/micronutrient deficiencies. Their requirements may increase during illness, and it must be addressed. In severe cases with weakness of chest muscles, nasogastric or percutaneous gastrostomy tubes are needed for nutrition." 

Vitrikas, K., Savard, D., & Bucaj, M. (2017), "Motor delays can be evaluated by one or more pediatric neurology, physical therapy, or occupational therapy subspecialists." 

Khan I, Leventhal BL. (2020), "The management of developmental delay is a team effort that includes primary care providers as well as pediatric subspecialists such as neurologists, child and adolescent psychiatrists, developmental and behavioral pediatricians, and other pediatric subspecialists as indicated. Also, the skills from other disciplines may be necessary, for example, psychology, genetics, speech and language pathology, occupational therapy, physical therapy, nutritionists, etc. In short, treatment strategies are usually multi-modal."     

Based on the medical documentation provided, the patient has a history of hypotonia with continued complaints of muscle weakness and difficulties with ADLs, strength, endurance, balance and safety. According to the medical literature, occupational therapy has been shown to be beneficial and play a crucial role in maximizing muscle function. Additionally, occupational therapy is recommended for pediatric patients to improve skills, especially fine motor and graphomotor skills, and their participation in educational and daily living activities. Therefore, the request for occupational therapy services for the time period under review is medically necessary. Therefore, the health care plan did not act in the best interest of the patient. 

The insurer's denial of coverage for ongoing occupational therapy (OT) services, codes 97110, 97112 and 97530 is overturned. Medical Necessity is substantiated.