Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a six-year-old male with a diagnosis of Joubert Syndrome.  The underlying disorder is an absence (complete or partial) of the cerebellar vermis with associated ataxia and motor in-coordination. In addition, the syndrome can include physical anomalies and mental retardation. The patient has been receiving physical and speech therapy since April 2002. The initial speech therapy request was to treat the patients inability to communicate, but these goals were abandoned in order to address issues related to swallowing. From a physical standpoint the patient has poor head and trunk control and functional goals have focused on improved sitting ability and quadruped.  The fathers request for reimbursement for speech and physical therapy services provided from January 2006 through May 2006 was denied by the Health Plan citing a lack of medical necessity.In evaluating the need for continuing therapies, a demonstration of functional gain is essential to a determination of medical necessity.  A review of the progress reports from speech therapy show limited progress in goal attainment or advancement of goals.  The progress report dated March 2005 identified two goals that had been met. Goal number one was described as an ability to demonstrate a calm body with no breath holding during touch around his face, his tongue, and  gums and hard palate, for up to 10 seconds in 8/10 trials.  Goal number two required the patient to imitate or produce oral postures in 4/5 trials, given tactile and verbal cues: lip pucker, open mouth, tongue protrusion and smile.  The February 2006 progress report provides no new goal advancing the skill attained through the accomplishment of goal number one. The second goal, although met in the March 2005 report, is repeated in the February 2006 report and described as an emerging goal. All other goals are unchanged from one progress report to the next and the gains reflected are qualitative at best. The documentation provided for review does not demonstrate an advancement of speech or language skills and little functional gain was achieved over the last year.  The physical therapy reports appear to be based on subjective observations and there is no objective data demonstrating the patient has made any functional gains since February 2005. The February progress report describes improvement from the status of no head control to an ability to hold his head up five minutes when engaged. However, the report does not document how often the patient is actually engaged (i.e. 4 of 5 trials, etc.).  In the follow up report dated December 2005, progress toward head control is described as good if  behavior is in control.  This assessment provides no objective evidence that the patient is in fact making gains toward head control.  Overall, standardized testing was not utilized to assess and document baseline status and/or functional gain and there is no objective measure of progress.  Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.