Appeal type: Medical necessity
Decision: Upheld

Diagnosis: rupture of anterior cruciate ligament of the left knee

Treatment: custom knee brace

The insurer denied coverage for custom knee brace.

The denial is upheld.

This is a young man who underwent anterior cruciate ligament (ACL) surgery with a non-complicated post operative course. He was evaluated by a Physician Assistant (PA) who recommended a custom knee brace. This was to allow participation in volleyball. The young man would not be "cleared" unless a brace was provided. His physical examination was unremarkable with no evidence of laxity. 

A brace has been found to be useful if there is ongoing instability or need to protect a recent surgical repair. This was not the case. 

The current literature summary for anterior cruciate ligament (ACL) brace after surgery, found at Official Disability Guidelines (ODG) 2023/Knee Brace after ACL and meniscal surgery:

No high-quality studies support or refute any benefits of knee braces for anterior cruciate ligament (ACL) tear, medical cruciate ligament (MCL) instability, or patellar instability; however, a knee brace might increase confidence for some patients, helping indirectly during the healing process. In all cases, initiation of a knee brace, when indicated, should be combined with an exercise program, only being necessary for a knee routinely stressed under load. (1) (2) (3) (4) (5) (6) (EG 1) There are few studies demonstrating that custom-fabricated functional knee braces offer any advantage over prefabricated, off-the-shelf braces in terms of activities of daily living. (7) (EG 2)

The use of bracing following ACL reconstruction (ACLR) cannot be rationalized by any evidence of improved outcomes including measurements of pain, range of motion, graft stability, or protection from injury. (8) (EG 1) Knee bracing after ACLR appears to be largely useless, according to a systematic review (SR). Post-operative bracing did not protect against re-injury, decrease pain, or improve stability. (9) (EG 1) Another SR of rehabilitation methods following ACLR also concluded that post-operative bracing has no benefit, accelerated strengthening improves outcomes, home-based rehabilitation is just as successful over the long-term, and there may be small but temporary benefits of proprioceptive training. (10) (EG 1) An SR of ACLR functional bracing simply concluded that "the effectiveness of post-operative functional bracing following ACLR remains elusive." Evidence remains too limited regarding routine use of functional bracing to decrease graft reinjury. (11) (EG 1)

These studies do not support the need for the "derotation brace." National Guidelines have not been met. 

A custom knee brace is not considered medically necessary for this patient. The records show no evidence of instability at any time. The records show weakness 4/5 which was improving. Weakness is not a recognized indication for brace in this clinical situation. There were no extenuating circumstances to substantiate use as recommended by the Physician Assistant. 

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 a custom knee brace services is not substantiated.