Diagnosis: Low muscle tone.
Treatment: Occupational Therapy.
The insurer denied the Occupational Therapy.
The denial is overturned.

The patient is a male child with history of feeding difficulties and diagnosis of low muscle tone of unknown etiology. He was referred for Occupational Therapy evaluation three years prior, at which time his mother had concerns about independence in self-help skills and ability to progress academically, socially, emotionally, and behaviorally. Historically, he had difficulty navigating his environment, with challenges in coordination. The Miller Function and Participation Scales (M-Fun) was administered to evaluate his abilities and level of functioning. He was willing to attempt all tasks but had difficulty when presented with a challenge. He required multiple verbal, visual, and tactile prompts to understand and follow through with instructions. He became progressively more fatigued during seated activities. Both test observations and home observations placed him far below average with participation. His visual motor and fine motor skills were noted to be borderline to mildly deficient and his gross motor skills were noted to be moderately deficient. He had some difficulty with bilateral motor integration as well as ocular motor skills. Based on his assessment, occupational therapy services twice weekly were recommended to address postural strengthening, endurance, body control, ocular motor skills, eye-hand coordination, and self-care tasks.

Yes, based on the occupational therapy evaluation performed, therapeutic services were medically necessary and appropriate for the period of time in question.

This school-aged boy underwent occupational therapy evaluation as a younger child because of concerns with poor strength and coordination. He had been evaluated for low muscle tone and no underlying cause was identified. However, comprehensive occupational therapy evaluation revealed deficits in strength, endurance, eye-hand coordination, self-care, and overall body control. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is well suited to address this child's issues and facilitate development of age-appropriate functional skills. The requested services were medically necessary and appropriate, consistent with the standard of care.