Cerebral Palsy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for a Tobii Dynavox Pilot® speech generating device with gaze interaction and mounting system. The primary rationale for the use of augmentative and alternative communication (AAC) is the inability of a patient to use natural speech to meet all of their daily communication needs. AAC may be used to augment or replace communication for patients with cerebral palsy who are unable to communicate with familiar and unfamiliar communication partners in all situations. Patients may use AAC regardless of their age or current cognitive skills. The use of AAC should encompass a life span perspective. The Researchers report that AAC is multimodal, permitting individuals to use every mode possible to communicate.

Physician 1The patient is an eight-year-old male who has pulmonary complications due to cerebral palsy. The patient has undergone gastrostomy. The patient’s provider and parents report it has been difficult to deliver chest physiotherapy (CPT). In addition, the patient continued to experience complications even with twice a day therapy. The submitted information indicates the patient has undergone a trial of the Vest Airway Clearance System (the Vest System) with good results. The Health Plan had denied coverage for the Vest System on the basis it is considered investigational for patients such as this patient.In view of the patient’s history of spasticity, gastrostomy, and frequent pulmonary infections, use of the Vest System is medically appropriate and indicated. The Vest System has been shown to be effective for patients such as this patient who cannot undergo postural drainage.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for sub-percutaneous myofascial lengthening (SPML) surgery. Current medical evidence has not demonstrated the superior efficacy of the requested services. Although researchers concluded that the SPML procedure combined with functional physiotherapy can improve gait function and lower-limb muscle strength, this conclusion was based on a small study of ten children. Researchers state, “Our findings hold promise for children with cerebral palsy and their parents, showing that children during ambulation indeed use the muscle-length gains as intended, as demonstrated by the goniometric measurements. In addition, subjects representing a range of levels of functional impairments improved their functional mobility in the environment.

The patient is a male diagnosed with cerebral palsy, hemiplegia, and generalized epilepsy. The provider noted that the patient has episodes of inattentiveness consistent with brief partial seizures. The patient has been treated with Botox injections, Depakene and Trileptal. The patient was treated with Diazepam for seizures lasting over three minutes or more than three seizures in one hour. The patient did not reportedly require rescue diazepam for seizures. The patient was noted to have one to five seizures per week, manifested by staring, with no convulsive activity and immediate return to baseline. The seizures were reported to last between 10 and 30 seconds. The patient’s parent has requested coverage for hours per month of home shift nursing care.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving cerebral palsy, then check the rights and deadlines that apply to your plan.