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202209-153223

2022

Excellus

Indemnity

Orthopedic/ Musculoskeletal

Durable Medical Equipment (DME) (including Wearable Defibrilllators)

Medical necessity

Overturned

Case Summary

Diagnosis: Plagiocephaly.
Treatment: Cranial orthotic (S1040).
The insurer denied coverage for a cranial orthotic (S1040).
The denial is overturned.

The patient presented for plagiocephaly. This was noted and recommendations for positional changes were employed, with minimal improvement in head parameters. There were no signs of torticollis. Therefore, physical therapy was not initiated. The physician recommended an orthotic for the left-sided plagiocephaly, based on worsening diameter changes.

Based on a review of the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. According to the policy, cranial orthotics are medically necessary when the child is three (3) to 18 months of age, has failed two months of conservative management, and has severe plagiocephaly where the skull axis has been rotated.

A cranial orthotic is considered medically necessary for this patient. The patient met all required criteria, and the usage of cranial orthotics is well-established in the literature:

According to Lam, S., et al. (2017), "Earlier age at presentation and type of treatment impact the degree of measured deformational head shape correction in positional plagiocephaly. This retrospective study suggests that treatment with a custom CO (cranial orthotic) can result in more improvement in objective measurements of head shape."

Per Kelly, K. M., et al. (2018), "These results demonstrate that the orthosis is successful in the treatment of deformational brachycephaly with an 81.4% improvement toward normal (95.0 to 89.4) in cephalic index."

In addition, Lam, S., et al (2017) states, "Patients with commercial insurance (OR (odds ratio) 1.49, 95% CI (confidence intervals) 1.10-2.02, p (probability) = 0.009), those diagnosed with both brachycephaly and plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a cranial orthotic (S1040) service is substantiated.

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