Pediatric Ortho: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for PreventionGenetics PGnome® Trio whole genome sequencing testing.Findings: Two of the three physician reviewers found the requested (PreventionGenetics PGnome® Trio whole genome sequencing testing is likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy. The clinical guidelines note that based on systemic evidence review, there is a strong recommendation to support the use of exome and genome sequencing (ES/GS) as either a first- or second-line test in patients with congenital anomalies (CA) with onset prior to age one, or developmental delay (DD) or intellectual disability (ID) with onset prior to age 18.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a Krabat Jockey Plus Chair for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment. This patient has a progressive neurodegenerative disorder characterized by extrapyramidal movement abnormalities, spasticity, cerebellar ataxia, and epilepsy. It affects strength and coordination, with development of severe dystonia, progressive spasticity, choreoathetosis, ataxia, and rigidity. It impacts speech and ability to chew and swallow effectively, resulting in dysarthria or anarthria. This patient requires specialized equipment in order to participate in activities of daily living while minimizing risk of complications.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parents of an enrollee has requested authorization and coverage for Botox injections.Botulinum toxin injection is a spasticity /dystonia treatment modality commonly used in children with neurological disorders, such as cerebral palsy, stroke and multiple sclerosis. A study by researchers found that adding botulinum toxin A injections did not significantly enhance the goal to walk either flat foot or with heel strike at 24 months posttreatment. In this case, there is no diagnosis of hypertonia or neurological disorder. The patient has idiopathic toe walking and a family history of toe walking. Serial casting is a reasonable option; however, there is no indication for botulinum toxin injection based on current quality literature.

The parent of a two-year-old male is requesting coverage for a cranial DOC band. The patient has been diagnosed with a cranial deformity secondary to left torticollis-plagiocephaly deformation sequence. The patient’s physician noted a difference in the patient’s cranial diagonal measurement of 0.5cm. A cranial DOC band was recommended. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary for treatment of the patient’s condition. Review of the current medical literature indicates most experts have not found benefit to band treatment after one year of age. Cranial band treatment is recommended for those with greater than 1cm differential, i.e., one ear greater than 1cm anterior over the other. Based on the records provided, the patient does not meet this criteria.

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