Diagnosis: Pilocystic astrocytoma
Treatment: Continued physical therapy services 2x/week x 12 weeks
The insurer denied the Continued physical therapy services 2x/week x 12 weeks.
The denial is overturned.

This is a child with history of infratentorial brain tumor (pilocystic astrocytoma) with ventricular hemorrhage. The tumor was resected a few years ago. Additional surgery took place the following year due to tumor recurrence. The patient developed posterior fossa syndrome. Skilled physical therapy interventions have been initiated in order to mitigate functional complications of posterior fossa syndrome that manifest itself with prolong ataxia and balance deficits. The patient has been recommended to continue physical therapy interventions provided by skilled pediatric physical therapist beyond 6 approved PT visits for dates. The most recent clinical evidence points out on the new tumor growth, and initiation of chemotherapy interventions in the nearest future.

Yes, continued physical therapy services is medically necessary.

This case involves is a child with infratentorial brain tumor and several surgical interventions who developed significant functional decline due to symptoms of posterior fossa syndrome. The patient has been receiving outpatient rehabilitative interventions that have been disrupted by the Covid-19 pandemic that led to several setbacks, and the need for further in person physical therapy interventions. Additional physical therapy is requested by the qualified healthcare providers with the personal knowledge of this child's clinical and functional status. Continued physical therapy services 2x/week x 12 weeks have been requested; the health plan has approved 6 visits. In addition, the patient has been recently diagnosed with recurrent brain tumor.

The patient is complaint with goal-oriented physical therapy interventions provided by the skilled professional under physician guidance. In this case, medical necessity for physical therapy interventions have been established.