Natalie D., a minor with cerebral palsy and arthrogryposis, has been eligible for state-funded therapy through California Children’s Services (CCS) since birth. Her mother paid for private physical therapy, including hippotherapy, and sought reimbursement from CCS, which denied her request but offered two 30-minute therapy sessions weekly for six months. An administrative law judge upheld CCS's decision, leading Natalie’s mother, as her guardian ad litem, to file a writ of administrative mandate in the superior court. The court denied the petition, affirming that hippotherapy is not considered medically necessary since similar benefits can be achieved through conventional therapies available in a gym setting. Additionally, the private services selected by Natalie’s mother did not qualify as vendor services under CCS guidelines. The court noted that from an early age, Natalie received therapy through CCS but faced numerous health challenges that limited the aggressiveness of her treatment. CCS had shifted her to a consultative basis due to lack of progress, and therapy was disrupted by various medical issues over the years. The case ultimately concludes that CCS's offerings met the necessary criteria for treatment, and that hippotherapy was not an essential service.
Hippotherapy, a physical therapy technique utilizing horse movement for sensory input, was not specifically aimed at improving Natalie’s balance or gait due to her immobility. Instead, it was partly intended to assist with her head control, which could also be addressed through other therapies, such as using an exercise ball or mats. Following a decline in Natalie's physical capabilities noted by Gilmour, a therapist who had previously worked with her, she showed some progress in hip range of motion and head control since 2009. A video presented at an administrative hearing depicted Natalie using equipment mimicking horse movement, while Gilmour indicated that such techniques were standard among physical therapists.
Norma Macias, Natalie's caregiver since 2007, observed significant changes in her condition, including the ability to sit up and hold her head up by June 2010. Dr. Afshin Aminian, Natalie's orthopedist, reported improvements in her hip flexion and trunk control in a November 2009 examination, attributing these advancements to her therapy at Shea. Despite ongoing concerns about the effectiveness of therapy provided by CCS, which prompted Natalie to seek private therapy at SKY, CCS proposed to increase her therapy frequency, an offer the mother rejected.
Lynn Einarsson Woods from CCS explained that their therapy gym is comparable to SKY's, except for one piece of additional equipment. CCS declined the mother's request for services through SKY and Shea, citing that Natalie's needs did not qualify for vendor therapy services and that hippotherapy is not a benefit under the CCS program, referencing Health and Safety Code section 123850. Following the denial of her requests to the Orange County Health Care Agency and subsequent appeal, Natalie sought a CCS Fair Hearing per California Code of Regulations, title 22, section 42180, subdivision (a).
The Fair Hearing, held over two days in June 2010, resulted in the administrative law judge denying Natalie’s second appeal for hippotherapy under California Children's Services (CCS), concluding that hippotherapy is not a recognized benefit. Following this, Natalie's mother filed a petition for a writ of administrative mandate in superior court, which upheld the judge's ruling. On appeal, the court reviews the superior court’s decision based on substantial evidence supporting the judgment, not on whether an alternative judgment could be supported. Under the Robert W. Crown California Children’s Services Act, the state is mandated to provide services to physically disabled children, contingent upon meeting specific criteria, including medical necessity determined by a CCS physician. The court found that hippotherapy does not meet the required standard of medical necessity for Natalie’s condition, affirming CCS's denial of the request for such services.
Uncontroverted evidence indicates that hippotherapy's benefits can be replicated through other gym-based therapies using non-equine tools, such as exercise balls or equipment that simulates a horse's movement. Dr. Aminian, Natalie’s orthopedist, supported continued treatment at Shea, but this recommendation alone does not necessitate CCS approval, as two conditions must be met: the physician's recommendation and the therapy being within CCS's scope of benefits. The Medical Therapy Conference, not just the physician, determines medical necessity for occupational and physical therapy. Dr. Dan Kouwabunpat, the conference doctor, evaluates medical necessity based on functional rehabilitation potential. The evidence suggests that the advantages of the $140/hour hippotherapy can also be achieved with equipment at a physical therapy gym, indicating it may not be medically necessary.
Additionally, any therapy plan must include measurable functional goals and objectives, which were not provided in the request for hippotherapy. CCS declined to cover treatments at SKY because the services were available at the MTU within 30 miles of Natalie’s residence, and there was no evidence supporting the need for vendor services. Although a claim was made regarding insufficient quality of therapists, the argument is insufficient for appeal, especially since evidence shows progress during treatment at SKY. However, inconsistencies in measuring hip flexion and Natalie’s previous health issues were noted, leading CCS to adopt a conservative approach. Therefore, substantial evidence supports that the requirements for vendor services were unmet, and the judgment is affirmed, with respondents entitled to recover costs on appeal.
