Microcephaly: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a Microcephaly Xpanded Panel. The cause of microcephaly can be difficult to discern as there are many genes contributing to microcephaly, either as an isolated finding in an individual or as part of an underlying syndrome. It is often necessary to perform testing of multiple genes (concurrently or as reflex tests) to identify the underlying genetic cause in an individual. Microcephaly can be caused by chromosomal abnormalities, inborn errors of metabolism, single gene disorders, trauma and infection. The inheritance patterns can be autosomal dominant, recessive or x-linked.

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old male has requested authorization and coverage for a Bantam stander for the treatment of the enrollee who has been diagnosed with microcephaly and global developmental delay. Findings: 2/3 of the physician reviewers found that the requested equipment is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. The device will enable the patient to assume a variety of functional positions and facilitate weight-bearing on his long bones. This is likely to decrease the risk of osteoporosis as well as decrease the risk of developing contractures of the hip, knees and ankles. There will also be a decreased risk of pressure sores. Appropriate positioning will aid the maintenance of normal gastrointestinal function.

Where the denial was upheld

The patient is a seven-year-old female with microcephaly, mental retardation and cerebral palsy with spastic quadriplegia. A detailed medical history was not submitted. The record indicates the patient was evaluated for outpatient physical therapy (PT) and participated from February 2006 to March 2006. She has also been evaluated for home therapies. The parent has requested that PT and OT be provided through a Home Health agency. The Health Plan denied his request based upon a determination that home therapies are not medically necessary.Concerns regarding the adequacy of the PT the patient has received thus far are valid. It is obvious from both the outpatient PT evaluation and the Home Health PT evaluation that neither therapist is experienced in treating children with cerebral palsy.

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old female enrollee has requested authorization and coverage for speech therapy. The requested weekly speech therapy sessions are not supported as medically necessary for the treatment of this patient’s speech delay as a result of her intellectual disability and microcephaly. The provider describes that her scores on standard testing have been unchanged over three evaluations at two year intervals, and that the patient’s rate of progress is consistent with her natural maturation. The patient has reached a plateau, thus the Health Plan’s recommendation for the patient to receive speech therapy for two sessions per month for the next six months, for diagnostic therapy, parent training and institution of a home program is appropriate.

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