Appeal type: Medical necessity
Decision: Upheld

Diagnosis: idiopathic toe walking

Treatment: ankle brace (L1970 x 2, L2220 x 4, L2280 x2)

The insurer denied coverage for ankle brace (L1970 x 2, L2220 x 4, L2280 x2)

The denial is upheld 

According to the medical records, the patient is a pre-school aged child, who has a history of idiopathic toe walking. The parents state he was a toe walker from the time he started to walk. He is able to put the foot plantigrade, yet only walks on his toes. He was referred to physical therapy in the past, but for some reason the note states he was unable to attend physical therapy in the past. Relevant physical findings demonstrate the patient is able to return to 0 at the ankle joint with the knee extended, and to 10 dorsiflexion with the knee flexed. There is no evidence of neurological deficit. Manual muscle testing is 5/5. The diagnosis is equinus. A prescription for physical therapy was provided. Stretching exercises were demonstrated. Night splints were recommended. Prescription for bilateral custom ankle - foot orthosis was provided.

The ankle brace (L1970 x 2, L2220 x 4, L2280 x2) is not considered medically necessary for this patient. Early treatment for young children with adequate range of motion (ROM) is generally reassurance because most young children with idiopathic toe walking are expected to resolve spontaneously. When the toe walking persists, treatment options include both surgical and nonsurgical management. Nonsurgical management centers on obtaining range of motion (ROM) through stretching and serial casting, followed by gait retraining and bracing treatment.

The medical records failed to document any evidence of physical therapy, serial casting, or stretching exercises prior to the prescription of the ankle foot orthosis. 

"Toe walking is a common presenting report to an orthopaedic practice. Evaluation of a child with toe walking includes a thorough history and physical examination to elucidate the diagnosis. When no other diagnosis is suspected, a diagnosis of idiopathic toe walking is often given. Despite the high prevalence of the condition, there is notable controversy of the nomenclature of the disease. Recent research has shed more light on both the natural history and the genetic basis. The use of motion analysis, including EMG and multisegment foot model, may help both differentiate children with mild forms of cerebral palsy and evaluate outcomes after treatment. Early treatment for young children with adequate range of motion (ROM) is generally reassurance because most young children with idiopathic toe walking are expected to resolve spontaneously. When the toe walking persists, treatment options include both surgical and nonsurgical management. Nonsurgical management centers on obtaining ROM through stretching and serial casting, followed by gait retraining and bracing treatment. Surgical lengthening at either the Achilles or gastrocnemius level improves the ROM of the ankle and then similarly requires therapy and bracing treatment to obtain a more normalized gait." (Bauer, J. P. et al. 2022).

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 ankle brace (L1970 x 2, L2220 x 4, L2280 x2) services is not substantiated.