Positional Plagiocephaly denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for a pediatric 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 authorization and coverage for a DOC Band cranial remolding orthotic device. Laughlin and colleagues found that positional skull deformities may be present at birth or may develop during the first few months of life and are generally benign and reversible. The authors recommended positioning and observation for mild-to-moderate deformity, noting that cranial orthoses should be reserved for severe cases of deformity or for the infant whose deformity does not improve after six months of age.

The patient is a seven-month-old male who during his two-month well-baby exam was noted to have mild torticollis and some flattening of the right occiput. Conservative treatment was discussed. At three-months of age, the baby had increased flatness at the back of his head, primarily on the right, and an anterior shift of the right ear. He was diagnosed with positional plagiocephaly and a cranial orthotic was advised. The baby was fitted for the device and his parents are now requesting reimbursement for the cost. The Health Plan has denied their request based upon a determination that the orthotic device was not medically necessary.Treatment of positional plagiocephaly with the helmet device is controversial. With babies now sleeping exclusively on their backs, we are seeing positional plagiocephaly commonly.

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