Diagnosis: Genetic Diseases/CHARGE Syndrome
Treatment: Physical Therapy/6 visits
The health plan denied the requested physical therapy visits as not medically necessary. The health plan's determination is overturned.

The patient is a female with CHARGE Syndrome and spastic quadriplegic cerebral palsy with severe scoliosis with pulmonary compromise. She is a poor candidate for the surgical correction of her scoliosis. Her orthopedic surgeon also notes supination and plantar flexion foot deformity for which they recommend intensive physical therapy to improve range of motion, gait and obtain bracing. Documentation notes that despite some pulmonary illnesses including COVID (coronavirus disease) and a pneumonia, there have been no plateaus in her progress with physical therapy.

The health plan's determination of medical necessity is overturned, in whole.

The requested treatment of 6 physical therapy visits are medically necessary for this patient.
There is a significant amount of research and peer reviewed literature that supports that exercise based physical therapies can be used to maintain and reverse the signs and symptoms of scoliosis in adolescents and adults. In this patient, who is not a surgical candidate for correction of neuromuscular scoliosis, intensive physical therapy directed at mobility, range of motion and positioning, and pulmonary rehabilitation is appropriate and fits medical necessity by preventing further deterioration of patient's condition. It is further documented that the patient was benefiting and progressing with 2x/week physical therapy, which further meets the medical necessity of helping the patient keep and improve skills of functioning for daily living.
Further, this patient is noted to have a supination and limited dorsiflexion deformity of her foot for which her orthopedic surgeon recommends intensive physical therapy, and this is also supported in the literature. Proper treatment of this foot deformity with physical therapy, bracing and gait training would improve patient's mobility and quality of life, again meeting medical necessity of her insurance plan.
I support 6 physical therapy visits additional, total of 12 physical therapy visits as medically necessary for this patient.