Plagiocephaly denials in California external review

What the reviewers wrote

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.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for a custom cranial remolding orthotic. 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. Presentation ranges from mild or moderate cases, that may respond to mechanical adjustments and exercises, to severe cases that are refractory to repositioning and may require surgery for correction.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for cranial remolding orthosis.Findings: The physician reviewer found that Positional plagiocephaly and deformational brachycephaly are terms used to encompass abnormal head shape due to a wide variety of etiologies and can range from mild to severe. Patients with mild and moderate plagiocephaly or brachycephaly may respond to mechanical adjustments and exercises. However, some patients present with severe and refractory to repositioning. The current treatment for patients with mild head shape abnormalities includes repositioning, physical therapy, and increased time in the prone position. Most providers currently recommend cranial orthoses for infant patients with moderate to severe skull deformities.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for DOC Band cranial remolding orthotic device. As noted in the records provided for review, this patient has a cranial vault asymmetry index (CVAI) of 6.2, cephalic index of 89.5, and a cranial vault asymmetry of 8 mm. Per the Plagiocephaly Severity Scale of the Children’s Hospital of Atlanta, the patient’s CVAI of 6.2 places him in the stage 2, mild range. The authors report that a CVAI of 3.5-6.25 with minimal asymmetry in one posterior quadrant and no secondary changes should be treated with a repositioning program. This patient is described as having right occipital flattening, left frontal flattening, anterior ear shift right, anterior orbital shift right and eye fissure narrowing left. This presentation includes some overlap with stage 3, moderate plagiocephaly.

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 plagiocephaly, then check the rights and deadlines that apply to your plan.