Congenital Deformity: 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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for a cranial remolding helmet. The submitted documentation supports the medical necessity of the equipment at issue. 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.

Where the denial was upheld

The patient is a nine-year-old male with a history of speech delays including expressive and receptive language deficits and decreased auditory memory and processing skills. He also has decreased intelligibility of his speech. By report, these deficits have affected his reading skills. No medical records are provided with details regarding other developmental milestones or medical history. The March 2005 evaluation noted that hearing is reported to be normal. The patient initially received three sessions of speech therapy beginning in March 2005, then resumed therapy in August 2005 through February 2006.

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for a Whole Exome Plus Analysis. The American College of Medical Genetics and Genomics (ACMG) published a guideline on the use of exome and genome sequencing in pediatric patients. The guideline recommends exome sequencing and genome sequencing as a first-tier or second-tier test for patients with one or more congenital anomalies prior to one year of age. The guideline notes, “Consistent with existing guidelines/recommendations/position statements, patients with clinical presentations highly suggestive of a specific genetic diagnosis should undergo targeted testing first.” This patient presents with bilateral congenital iris cysts, ciliary body involvement, and anterior chamber anomalies.

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 congenital deformity was denied, the published record says the denial is worth fighting.