Braces denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with adolescent idiopathic scoliosis of the thoracolumbar region. The documentation noted that she has been using a brace. The provider noted that the patient appeared to be realigning in the brace, and the expected outcomes would be achieved. The patient’s brace was noted to be too small, as she had grown four inches. Physical examination findings included an elevated shoulder height bilaterally, right scapular prominence, and waist asymmetry. The thoracic spine alignment was hypokyphotic, and the lumbar alignment was hypolordotic. Thoracic prominence (rib rotation) on the right was noted at eight degrees and lumbar paraspinal prominence was noted on the left at six degrees. The provider noted that a new brace was indicated.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for a Dynasplint device. Findings: The physician reviewer found that Furia and colleagues conducted a systematic review to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes. They concluded that dynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. John and colleagues conducted a randomized controlled trial to determine the efficacy of dynamic splinting in treating patients with postoperative hallux limitus. They concluded that dynamic splinting was effective in reducing contracture of postoperative hallux limitus.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for bilateral knee braces for treatment of the enrollee’s knee injury. Findings: The physician reviewer found that the evidence-based medical guidelines state that there are limited high quality studies that support or refute the benefits of knee braces for patellar instability, ACL tear, or medial collateral ligament instability. However, studies have found that in some patients a knee brace can increase confidence, which may indirectly help with the healing process. Pre-fabricated knee braces may be appropriate for patients with knee instability or ligament insufficiency/deficiency. Custom braces are supported when there is abnormal limb contour, such as disproportionate thigh and calf, precluding the use of a pre-fabricated brace.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a right brace for treatment of her anterior cruciate ligament (ACL) injury. Findings: The physician reviewer found that the standard of care in the setting of therapy for anterior cruciate ligament (ACL) injuries is physiotherapy with a focus on recovery of strength, range of motion and agility. When relevant, this is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition. If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion restored. A neoprene sleeve can be used as an option for additional support. However, a functional ACL brace has not been proven in the medical literature to be an effective intervention for this condition.

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