Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Palsy

Treatment: Custom-made boot/brace (L1970 x 2, L2200 x 2, L2275 x 2, L2820 x 1, L2280 x 2)

The insurer denied coverage for Custom-made boot/brace (L1970 x 2, L2200 x 2, L2275 x 2, L2820 x 1, L2280 x 2.)

The denial is overturned.

This case involves a female child diagnosed with extreme ankle tightness consistent with spastic quadriparesis associated with cerebral palsy, who was being recommended for custom made boot/bracing.  The patient was being recommended for prescription bracing.  She was using bilateral hinged ankle-foot orthosis with her mother noting that 2 years prior, her hip was 30% displaced with no prior x-rays or records available.  The patient's mother stated the patient is unable to walk without braces.  The patient was holding her arms in pronation and had a naturally bent knee posture.  She was not sleeping well, had a low appetite, and was being treated with physical therapy and electrical stimulation.  1 year prior, the patient began taking independent steps, but required a break after 100 steps.  She needed braces to walk and otherwise crawled as a mode of transportation.  X-rays were reviewed revealing that the hips appear located with increased neck shaft angles.  The knees were flexed and the images with growth plates appearing to be intact.  The plan was to determine proper bracing based on the video materials received by the patient's mother via email and then order new bracing at that time.  

Multiple letters were received from different sources explaining that the patient has extreme ankle tightness consistent with spastic quadriparesis and cerebral palsy.  She is capable of walking with assistance of the braces.  It was also explained that the patient suffers from skin breakdown in the ankle area and that the interface padding is a crucial part of the brace.  Other letters stated that the patient's current ankle-foot orthoses are small as they were fabricated more than a year prior, and the patient has since grown.  

Literature notes that children with cerebral palsy experience functional limitations because of excessive muscle weakness, spasticity, and impaired motor control.  The patient in question needed new custom bracing for the lower extremities given her spastic quadriparesis associated with cerebral palsy with extreme ankle tightness.  Because the patient continues to grow and needs proper fitting devices to promote a dynamic gait and prevent additional breakdown of the skin of the ankle area, the interface padding, and the custom-made devices are essential for this individual.  The information provided for the review noted that the patient has bracing that helps her ambulate independently.  However, because the patient was fitted for these braces over a year before and has since grown, they are now small and causing skin breakdown.  It was therefore determined that custom-made boot/braces would be appropriate and within the standard of care to meet the needs of this individual.  Based upon the provided information, the current request is supported.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Custom-made booth/brace (L1970 x 2, L2200 x 2, L2275 x 2, L2820 x 1, L2280 x 2) services is substantiated.