Torticollis: when insurers say no, reviewers often say yes

Where the denial was overturned

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for a cranial remolding orthosis device. The submitted documentation supports the medical necessity of the cranial remolding orthosis, measurements, and adjustments provided to this pediatric patient. Positional plagiocephaly describes an abnormal head shape due to a wide variety of etiologies. Prenatal causes include the fetal head resting 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. Mild and even moderate cases of plagiocephaly may respond to mechanical adjustments and exercises. However, there are some patients that are refractory to repositioning.

Where the denial was upheld

The parents of an eight-month-old male diagnosed with torticollis and plagiocephaly are requesting authorization of cranial orthotic therapy. Reviewer’s Findings: The reviewing physician found that the record indicates the parents have attempted repositioning, but there is no evidence physical therapy has been attempted. Therefore, a two-month trial of physical therapy should occur before proceeding to cranial orthotics. The reviewing physician found that the Health Plan denial should be upheld.

The parents of a one-year-old male with a history of torticollis with positional plagiocephaly are requesting authorization of physical therapy.Reviewer’s Findings:The reviewing physician found that based on the submitted therapy notes and progress report, it appears that the patient has made sufficient gains and therefore, it is medically appropriate to transition him to a home program performed by his parents. The reviewing physician found that the Health Plan denial should be upheld.

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