Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fine Motor Developmental Delay
Treatment therapeutic activities (97530)
The insurer denied coverage for therapeutic activities (97530)
The denial is modified

This is a child with a history of a fine motor developmental delay. Short term goals of therapy include demonstrating the ability to independently carry out multi step directives and integrating varied novel body positions with the ability to accurately replicate steps after the initial direction.

Long term goals for the child in occupational therapy (OT) were to improve sensory modulation, improve self regulation abilities, improve attention/safety awareness, improve core/postural stability, improve motor planning activities needed for increased engagement with age based occupational performance tasks across settings. 

There were no functional outcome measurements that were included in the documents submitted for review. There was no objective reports included that can gauge the child's response to therapies provided. The OT note shows that the patient had made slow gains towards reaching goals. He could carry out multi-step directions and integrating varied novel body positions. He needed moderate cues to accurately replicate steps after initial directions. Minimal progress was made towards the feeding goal due to focus of treatment was on gross motor goals.

In order to approve this service, the following criteria must be met: 1. there must be a requirement of professional one to one supervision to complete the activity; 2.  the time component of the services rendered must be documented; 3, a description of services done; 4. the area of application must be documented. 

Some of the guiding principles in the management of developmental problems include: 1) individualizing the approach according to the child's strengths, weaknesses, self concept, goals and opportunities. 2) actively involving the child 3) prioritizing functional skills that are relevant to everyday activities and are important to the child and parents 4) teaching specific skills that can be generalized or transferred to other activities 5) including accommodations for home and school, 6) involving multiple individuals in the treatment plan.

In addition to supportive care and treatment of associated conditions, children with fine motor delays should receive interventions such as OT to improve motor skills and function.  For children with delays in development, physical therapy (PT) or OT is recommended, rather than no intervention. Therapy has been associated with short term improvement in skills in children with developmental coordination disorder. 

There is little information to guide recommendations for frequency or duration of therapy. Of the submitted documentation only the one dated progress notes contain the details necessary to support medical necessity.  Almost all the other notes are very brief one liner comment - often identical to prior date. Thus,  modify the Insurer's decision to deny coverage for all OT services except one date in question. OT services on all the other dates were not supported by the documentation  except for one. The healthcare plan acted reasonably in part with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for three units of therapeutic activities (97530) provided on multiple dates are upheld and one therapeutic service date is reversed. Medical Necessity is substantiated for one day only.