Brachycephaly: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cranial orthotic helmet. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollee’s abnormal head shape (plagiocephaly).Findings: There is scientific evidence demonstrating that the requested equipment is effective in this clinical setting. Positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface such as the mother’s pelvis or the limb of a sibling in a multiple gestation pregnancy for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for a custom cranial remolding orthotic. Positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes may include the resting of the fetal head against a hard surface, such as the mother’s pelvis or the limb of a sibling in a multiple gestation pregnancy, for a prolonged period, while postnatal causes are more common and may include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep positions. Presentation ranges from mild or moderate cases, that may respond to mechanical adjustments and exercises, to severe cases that are refractory to repositioning and may require surgery for correction.

Where the denial was upheld

This patient is an 11-month-old male with a diagnosis of brachycephaly and plagiocephaly. With brachycephaly, the predominant condition measurements demonstrate a cephalic index greater than 2 standard deviations above the norm and an asymmetry of the cranial vault of 4.5 mm. At issue is whether a cranial remodeling orthosis is medically necessary for treatment of the patient’s brachycephaly and plagiocephaly.Review of the medical evidence demonstrates that a cranial orthotic does not improve brachycephaly. Plagiocephaly of 4.5 mm without evidence of brachycephaly often corrects with time and positioning. The only study looking at both plagiocephaly and brachycephaly (Teichgraker) documents little effect on brachycephaly. For these reasons, the requested device is not likely to be of clinical value in this setting and is not medically warranted.

The parent of an eight-month-old male enrollee has requested a cranial remolding orthosis (DOC band) for treatment of the enrollee’s plagiocephaly and brachycephaly. Findings: The physician reviewer found that the records do not indicate that the patient has cervical motion restriction. In addition, there is no documentation of skin complications other than dermatitis noted that pre-dates the cranial orthotic device application. Moreover, no documentation was provided of a skin complication that impacted the utilization of the cranial orthotic device. Further, the patient does not have cephalic index that is more than two standard deviations from the mean. Given the documentation provided for the review, the cranial orthotic device is not medically necessary for treatment of this patient’s medical condition.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for brachycephaly was denied, the published record says the denial is worth fighting.