Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for sub-percutaneous myofascial lengthening (SPML) surgery. Current medical evidence has not demonstrated the superior efficacy of the requested services. Although researchers concluded that the SPML procedure combined with functional physiotherapy can improve gait function and lower-limb muscle strength, this conclusion was based on a small study of ten children. Researchers state, Our findings hold promise for children with cerebral palsy and their parents, showing that children during ambulation indeed use the muscle-length gains as intended, as demonstrated by the goniometric measurements. In addition, subjects representing a range of levels of functional impairments improved their functional mobility in the environment. Subsequent program implementation studies support the safety of the minimally invasive SPML release of the lower extremities based on the low complication and low reoperation rates. Future studies may determine the place of SPML techniques within the context of conventional methods and, if studies include multicenter collaborations between surgeons skilled in the techniques, may investigate the optimal age for these interventions to enhance the development of children with cerebral palsy and provide hope and encouragement to their caregivers. In this case, notes reported that the patient is being treated for GMFCS-5 cerebral palsy. The records noted regular surveillance and follow up of bilateral planter flexed contracture of the feet, scoliosis, and left hip dysplasia. The patient tended to flex her calves, causing her bilateral feet to plantarflex, and tended to flex the right flank of the body more, causing the torso to bend to the right. An examination revealed palpable defects of the spine and left-sided curvature largely corrected with traction. The records noted stiff range of motion with abduction of the shoulders above 100 degrees bilaterally. The arms adducted and were internally rotated at the shoulder. The lower extremities showed stiff passive knee flexion and bilateral ankle fixed at plantar flexion, and the patients hips were not level. While there are studies showing promise and support for SPML release of the lower extremities, there is still a need for further studies to overall indicate this procedure as an effective and/or safe treatment, supported by published, large-scale, long-term peer-reviewed literature. Therefore, SPML surgery is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested SPML surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts 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.