Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental Delay
Treatment: 20 More Outpatient Physical Therapy Visits
The insurer denied: 20 More Outpatient Physical Therapy Visits
The denial is overturned.

The patient is a toddler child with complicated medical history significant for myelomeningocele status post repair, Chiari II malformation status post right ventriculoperitoneal shunt with multiple revisions. He has participated in outpatient physical therapy twice weekly at a specialty hospital since initial evaluation, actively participating in interventions focusing on strengthening, balance training, postural alignment, and gross motor skill acquisition. 
The patient was approved for Early Intervention services but only telehealth therapy was available. Local facilities providing Early Intervention services had no availability. This toddler has made excellent progress, now able to stand independently, taking four to five steps unsupported. However, the patient has ongoing deficits in strength, balance, motor control, and postural alignment that negatively impact his functional mobility. Twice weekly in person intervention has been recommended for twenty weeks to facilitate age-appropriate gross motor skills, decrease his risk of falling, prevent development of deformities from poor alignment, and provide family training.

The proposed 20 additional outpatient physical therapy visits are medically necessary.

Physical therapy is a key component in the proper growth and development of children with myelomeningocele. Physical therapists are involved in assessing neurologic and motor level, monitoring for any changes in that level over time, assessing baseline and subsequent acquisition of skills, supporting efforts to incorporate mobility within the home environment, collaborating with orthopedic surgeons to monitor and address any specific musculoskeletal problems, and assessing need for durable medical equipment.
This young child participated in direct physical therapy from his initial evaluation forward. While he has been approved for Early Intervention services, there are no in-person services available. Most recently, the patient has demonstrated improvements in standing balance and ambulation. He is able to stand independently for three minutes and can take up to five steps with close supervision. Despite his progress, he continues to lag significantly behind same-aged peers in gross motor skills and ambulation. As children age, tasks and activities become more complex and this child will fall further behind without the appropriate therapeutic support. Telehealth physical therapy (PT) has become more common as a result of the pandemic, perpetuated by overall better access to care. However, there are currently no peer reviewed articles or scholarly discussions evaluating remote versus in-person therapy for children with myelomeningocele. 
This child has demonstrated success with his current therapy situation, and he requires additional therapeutic support. The requested twice weekly physical therapy services is medically necessary and appropriate for twenty visits with evaluation at that time to determine need for ongoing care.