Diagnosis: muscle weakness
Treatment: physical therapy
The insurer denied physical therapy. The health plan's determination is overturned.

The patient is a male who has a diagnosis of lack of coordination, muscle weakness (generalized), unspecified abnormalities of gait and mobility, delayed milestone in childhood, specific developmental disorder of motor function.

The requested physical therapy is medically necessary for this patient.
Per results of the Peabody Developmental Motor Scores performed the patient was less than 10th percentile in all domains he does meet the criteria for medical necessity.

The patient's developmental delays do meet the threshold for which specialized intervention is warranted. The patient has some areas of improvement though deficits still are present. The therapy in question does meet these standards of care for medical necessity. Physical therapy is medically necessary when there is documentation that it is improving a patient's current condition, or preventing or slowing further deterioration of the patient's condition, or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition.