Issued and entered January 8, 2003 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On June 24, 2002, XXXXXXXXXXXXXX filed a request for external review on behalf of her dependent XXXXXXXX, XXXXXXXXXXX (Petitioner), with the Commissioner of Financial and Insurance Services (“Commissioner”) under the Patient’s Right to Independent Review Act (PRIRA), MCL 550.1901et seq. After a review of the material submitted, the Commissioner accepted the request for review on July 1, 2002.
Since a determination on medical issues was required, the case was assigned to National Medical Reviews, Inc. (NMR), an independent review organization (IRO), to provide its recommendation to the Commissioner. Physicians Health Plan of Mid-Michigan (PHPMM) submitted a position paper to the IRO dated July 8, 2002. The IRO completed its review on July 18, 2002, and forwarded a copy to OFIS. XXXXXXXXXXX

II
FACTUAL BACKGROUND

Petitioner is a XXXXXXXXXXXXXXX member of PHPMM covered, as a dependent under her mother’s Certificate of Coverage through her mother’s employer, XXXXXXXXXXXXXXX. Petitioner is diagnosed with Cerebral Palsy. Her main disability is lack of full use of her legs.
In this case, Petitioner’s mother seeks coverage of hippotherapy treatment for Petitioner. Hippotherapy treatment is therapy using horseback riding. The hippotherapy in this case was provided by a non-participating provider, XXXXXXXX XXXXXXXXXXX, XXX. (XXXX) of XXXXXXXXX, Michigan. Petitioner’s hippotherapy is used to improve her mobility and to strengthen the muscles in her upper and lower body. Petitioner’s hippotherapy sessions are currently one day a week. Petitioner’s mother claims Petitioner actually requires two hippotherapy sessions per week. These sessions cost $20.00 per week. There is also a $34.00 yearly fee.

PHPMM denied Petitioner’s request for hippotherapy on the basis it is not a benefit under Petitioner’s HMO Certificate of Coverage. The case was submitted to the IRO for review on the issue of whether hippotherapy is a covered benefit.

III
ISSUES

Whether PHPMM may properly deny Petitioner coverage for out-of-network hippotherapy treatment?

IV
ANALYSIS

Petitioner’s Position

Petitioner’s mother claims that Petitioner needs a lot of therapy to treat her cerebral palsy. Petitioner’s mother claims that Petitioner’s main problem is not having full use of her legs. Petitioner’s mother claims Petitioner needs hippotherapy treatments to improve her mobility and to strengthen the muscles in her upper and lower body. Petitioner’s mother claims that hippotherapy is improving her daughter’s muscles so that she may one day be able to walk independently.

Petitioner’s mother said Petitioner has been undergoing hippotherapy for some time. Petitioner’s mother states she does not want to see Petitioner’s hippotherapy stop because it has been working well for her. She claims as a result of this therapy, Petitioner has seen great improvement in her ability to move. Petitioner’s mother claims that, in the past year, Petitioner has learned how to use her walker very well and is in the process of learning how to use Loft strand arm crutches. Petitioner’s mother further claims that, in XXXXXXXXXXXXX, her XXXXXXXX began to be able to take steps independently. Petitioner’s mother claims that if Petitioner’s hippotherapy is stopped now, her development could be put on hold, and Petitioner could lose all that they have worked so hard to accomplish.

Documentation from XXXX indicates that the goal of hippotherapy is to achieve therapy goals not to teach riding skills. XXXX claims that the three dimensional gait of a horse closely simulates the movement of the human pelvis while walking and is unique and valuable as a treatment tool. XXXX claims that the horse’s movement provides a systems wide impact that reaches physical, cognitive, emotional, and psychosocial areas of performance.

XXXX claims that clients with various impairments such as Cerebral Palsy, Autism, Developmental Delay, Muscular Dystrophy, Multiple Sclerosis, Traumatic Brain Injury, Arthritis, Scoliosis, Spinal Cord Injury may benefit from hippotherapy. XXXX states that each hippotherapy session is a client-centered approach with a staff occupational or physical therapist. XXXX claims that all precautions and contra-indications as prescribed by its national governing body, XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, and by the XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, apply to its program’s services.

Petitioner’s mother claims that four physicians supported her request, for hippotherapy for Petitioner. Petitioner’s mother provided the names, addresses, and physician types of these physicians; however, she did not provide documentation from any of these physicians.
Petitioner’s mother claims that PHPMM should approve the referral and pay for the coverage for the hippotherapy treatment because to stop the services now would put Petitioner’s development on hold and Petitioner could lose all that she has worked so hard to accomplish.

PHPMM’s Position

PHPMM presents three reasons for why hippotherapy should not be a covered benefit. First, PHPMM claims that hippotherapy is excluded as a sports-related/physical conditioning activity. Second, PHPMM claims hippotherapy is excluded as an alternative treatment. Third, PHPMM claims hippotherapy is excluded as experimental, investigational or unproven treatment.

PHPMM states that Section 11-1Y of the Certificate of Coverage excludes hippotherapy treatment because it is a sports related activity. PHPMM states that Section 11-1 AJ of the Certificate of Coverage excludes hippotherapy treatment because it is an excluded alternative treatment for cerebral palsy. PHPMM claims that the fact there are limited research studies related to animal assisted therapy and hippotherapy specifically shows that hippotherapy is alternative therapy. PHPMM claims that until hippotherapy is an accepted therapeutic modality it is an excluded alternative therapy under Petitioner’s benefit contract. PHPMM claims that Section 11.1H of the Certificate of Coverage excludes hippotherapy coverage because it is constitutes experimental, investigational or unproven, treatments.

IRO’s Review:

The IRO recommended that PHPMM’s denial of coverage of hippotherapy be upheld. In support, the IRO claims that there is no documentation from any treating physicians regarding hippotherapy for Petitioner’s XXXXXXXX.

The IRO pointed out that PHPMM denied coverage of hippotherapy for Petitioner because it is considered a sports-related/physical condition activity, an alternative treatment, and experimental, investigational or unproven treatment. The IRO indicated that the study provided in the records did not provide any significant improvement in overall gross motor scores than is provided by conventional and medically proven techniques (i.e., physical and occupational therapy). The IRO also indicated that here is an inherent risk from hippotherapy of falling from a horse and getting hurt.

The IRO added that hippotherapy does not comply with Sections 11.1A 11.1E 11.1H 11.1X and 11.1Y of the benefit contract. The IRO concluded that hippotherapy is not supported at this time because of the risk for injury and because it has not been proven for Petitioner’s daughter’s age group. Additionally, the IRO noted that conventional forms of therapy could be used for Petitioner.

Commissioner’s Review

The Commissioner supports the final adverse determinations of PHPMM and the recommendation of the IRO. The Commissioner finds that the requested services do not comply with the PHPMM benefits offered under Petitioner’s plan contract purchased by her employer. Specifically, the Commissioner finds that Petitioner’s hippotherapy is excluded from coverage by Section 11-1Y since it involves a sports-related/physical conditioning activity. Additionally, the Commissioner finds that hippotherapy is excluded from coverage by section 11-1 AJ since it is an alternative treatment. Finally, the Commissioner finds that hippotherapy is excluded by Section 11-1H since it constitutes an experimental, investigative or unproven treatment.

V
FINAL ORDER

Therefore, the Commissioner ORDERS that the final adverse determination issued on April 8, 2002, by PHP-MM denying coverage for hippotherapy is upheld.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.