Diagnosis: Cerebral Palsy
Treatment: 24 Physical Therapy and 24 Occupational Therapy Visits
The insurer denied the 24 physical therapy and 24 occupational therapy visits.
The denial is upheld.

The patient is a teenaged female with a history of cerebral palsy, developmental delay, and seizure disorder. She lives in the community with family. She is blind in both eyes and nonverbal. She is on supplemental oxygen and on continuous tube feeds via gastrojejunostomy tube. She is restricted from intake by mouth. She is incontinent of bladder and wears an incontinence brief. She has been followed by home health services. She has generalized weakness, fine motor deficits, limb contractures (at the bilateral shoulders, wrists, hands, knees, and ankles), impaired endurance, and pain issues. She has been dependent for all care and mobility including transfers. She is passively transported via wheelchair with total assist. She has been receiving occupational and physical therapies for at least 3 years, which has included passive range of motion and family/caregiver training. The therapists have worked on attempting to engage the patient to show some participation in activities such as rolling.

The health plan denied coverage of the service under review, indicating that the service is not medically necessary as they do not support a skilled plan of care. The denial is being appealed.

The requested 24 physical therapy and 24 occupational therapy visits are not medically necessary.

There are no indications in the records of any functional or health goals requiring ongoing skilled physical therapy or skilled occupational therapy services. The patient has already undergone therapies where caregivers were provided training to assist the patient. The patient otherwise has not shown any capacity to actively and meaningfully participate in therapies towards functional or other clinically meaningful goals. Additional formal therapy services are not expected to improve the patient's outcomes based on the patient's conditions, history, and examination findings, including her developmental delay, contractures, and history of total dependence for all care and mobility.