Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

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 patients 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. In a letter, the patients parent reported that the provider had recommended the patient be fitted with a LA scoliosis brace by a specific orthotist. She had recently outgrown her brace and needed a new one. This orthotist specializes in scoliosis bracing and was the only California provider of the more advanced LA 3D scoliosis brace. The patients parent has requested authorization and coverage for a LA 3D scoliosis brace. The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a LA 3D scoliosis brace is medically necessary for the treatment of the patients medical condition. Researchers reported that bracing is supported by high quality evidence. Asymmetric braces have led to better corrections than that described for symmetric braces. An improvement of the average corrective effect has been described due to the latest CAD/CAM development. Long-term corrections are possible when starting brace treatment early, at an immature stage and with asymmetric braces of recent standards. Studies reported that, The combination of numerical simulation and CAD/CAM approach allowed designing more efficient braces in all three planes, with the advantages of being lighter than standard CAD/CAM braces. Bracing in adolescent idiopathic scoliosis (AIS) may be improved in 3D by the use of this simulation platform. Authors reported, Curve progression and referral to surgery are lower in patients with high brace compliance. Bracing discontinuation up to one month does not impact on the treatment outcome. Conversely, wearing the brace only overnight is associated with a high rate of curve progression. In this case, the patient has been treated with a 3D computer aided design and manufactured LA 3D scoliosis brace over the past year, with significant improvement in both her thoracic and lumbar curvatures. She requires a replacement brace, as she has grown four inches and the brace no longer fits. She has been compliant with 22-hour per day use of this brace for the past year. The medical evidence supports the requested device in this clinical setting. Therefore, a LA 3D scoliosis brace is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.