Appeal type: Medical necessity
Decision: Upheld

Diagnosis: idiopathic toe walking

Treatment: medical equipment custom ankle foot orthosis (L1970 L2820 L2275) X 2

The insurer denied coverage for medical equipment custom ankle foot orthosis (L1970 L2820 L2275) X 2

The denial is upheld

 
This is a young child who has been diagnosed with anxiety, attention deficit hyperactivity disorder (ADHD) and idiopathic toe walking. The patient has tried and failed physical therapy (PT). The request is for custom ankle foot orthosis (AFOs) (L1970 L2820 L2275) (x) times two (2) for tripping safety and gait training, which is under review.

The patient has not tried and failed standard bracing, nor is there any demonstration by history or exam to show that multiple joints need stabilization, such as the knee. The patient should initially try more conservative measures, such as standard bracing. As such, the denial is upheld.

Per Caserta, A. J., et al., (2019), "Young children and children without a limitation in ankle dorsiflexion (the upwards movement of the foot towards the shin of the leg) are commonly treated with conservative interventions. One study recruited 80 children and reassessed them three to eight years after initial presentation. Of these, 48 children did not receive active intervention (but were observed over time, wore modified footwear, or performed gastrocnemius and soleus stretching exercises under the supervision of a parent or healthcare professional). The study concluded that persistent toe walking did not result in significant functional disturbance, foot deformities, or pain."

Per Brasiliano, P., et al., (2023), "Idiopathic toe walking (ITW) is a gait deviation characterized by forefoot contact with the ground and excessive ankle plantarflexion over the entire gait cycle observed in otherwise-typical developing children. The clinical evaluation of ITW is usually performed using optoelectronic systems analyzing the sagittal component of ankle kinematics and kinetics. However, in standardized laboratory contexts, these children can adopt a typical walking pattern instead of a toe walk, thus hindering the laboratory-based clinical evaluation. With these premises, measuring gait in a more ecological environment may be crucial in this population. As a first step towards adopting wearable clinical protocols embedding magneto-inertial sensors and pressure insoles, this study analyzed the performance of three algorithms for gait events identification based on shank and/or foot sensors. Foot strike and foot off were estimated from gait measurements taken from children with ITW walking barefoot and while wearing a foot orthosis. Although no single algorithm stands out as best from all perspectives, preferable algorithms were devised for event identification, temporal parameters estimate and heel and forefoot rocker identification, depending on the barefoot/shoed condition. Errors more often led to an erroneous characterization of the heel rocker, especially in shoed condition. The ITW gait specificity may cause errors in the identification of the foot strike which, in turn, influences the characterization of the heel rocker and, therefore, of the pathologic ITW behavior."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for medical equipment (L1970 L2820 L2275) X 2 is not substantiated.