Leg Length Discrepancy denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient’s parent has requested authorization and coverage for hip to ankle scanogram/EOS imaging. The Health Plan denied the request and reported the requested services are not medically necessary for the evaluation of this patient. Researchers concluded that the “identification of congenital and acquired etiologies causing alignment disorders and leg-length discrepancies (LLD) in children is important for management.” Per the authors, “LLD of greater than 1 cm can cause altered biomechanics, resulting in scoliosis, back and lower extremity joint pain, pelvic tilt, abnormal gait and premature degenerative joint disease.” Medical literature states “upright EOS protocols that utilize a faster speed and lower current are more accurate than CT scanograms and conventional radiographs for the assessment of length and also are associated with a significantly lower radiation exposure.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left shoe orthotics. Studies indicate that limb length discrepancies more than 2.0 cm are frequently problematic and hip and knee pathology is present in an increased number of patients with limb length discrepancies over 0.5 cm. In addition, low back problems are reportedly common on same side of the body as the shorter limb. Studies concluded that the evidence suggests that gait deviations may occur with leg length discrepancies of more than 1.0 cm, with greater impact seen as the discrepancy increases. This patient presents with a history of severe trauma to the left lower extremity resulting in left foot and leg deformity. She is status post multiple reconstructive procedures, including left foot and ankle fusion with heel reconstruction.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hip revision surgery. The records indicate that this patient is being treated for osteoarthritis of the right hip. The patient underwent a total hip replacement for the right hip with a revision secondary to recurrent dislocations. Per the operative note, she had a dual mobility hip implant placed without any change in the femoral stem or acetabular component. The patient presented for a third opinion regarding a possible revision secondary to leg length discrepancy. The records do not specify the numeric quantity of the discrepancy. The patient has requested authorization and coverage for hip revision surgery.

Findings: The physician reviewer found that a patient has requested authorization and coverage for a femoral derotational osteotomy procedure performed to either or both femurs and/or a tibial osteotomy procedure performed to either or both tibias. This patient is being treated for leg length discrepancy, retroverted hips, and right femur bowing. The patient underwent a right femoral shortening osteotomy with intramedullary fixation and a right proximal femoral derotational osteotomy approximately two years ago. The patient presented most recently less than two months ago with pain over the bilateral hips and continued bilateral knee pain.

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 leg length discrepancy, then check the rights and deadlines that apply to your plan.