Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Scoliosis. 
Treatment: Back Device (self-operated spinal unloading device; code L1499). 

The insurer denied the back device (self-operated spinal unloading device; code L1499).  The denial was reversed. 

This is a young female patient with adolescent idiopathic scoliosis.  The patient had a Cobb angle of 31 degrees on the right on T4-T10 and 38 degrees on the left on T10-L3.  Her recent office visit notes indicated that the patient had a trunk shift to the left.  On Adams forward bend test there were left thoracolumbar and smaller right thoracic prominences.  The patient's strength and muscle tone was normal and symmetric throughout her upper and lower extremities.  The patient's toes are downward with Babinski test.  The patient's Galeazzi was negative, and the patient had no clinical evidence of a leg length discrepancy.  The diagnostic imaging showed right thoracic curve of 31 degrees, left lumbar curve of 38 degrees, Kyphosis T2-T12 of 22 degrees, lordosis L1-S1 of 58 degrees, and Risser 0 and Sanders 3.  The patient's treatment plan included calcium 600mg and vitamin D 800 IU daily.  The treating provider requested the use of a Rigo Cheneau brace for the patient. 

The scientific evidence in peer-reviewed literature supports that bracing results in improvement of health outcome for patients diagnosed with adolescent idiopathic scoliosis. 

According to Gomez, Hresko & Glotzbecker (2016), "Pediatric patient visits for spinal deformity are common.  Most of these visits are for nonsurgical management of scoliosis, with approximately 600,000 visits for adolescent idiopathic scoliosis (AIS) annually.  Appropriate management of scoliotic curves that do not meet surgical indication parameters is essential. Renewed enthusiasm for nonsurgical management of AIS (e.g., bracing, physical therapy) exists in part because of the results of the Bracing in Adolescent Idiopathic Scoliosis Trial, which is the only randomized controlled trial available on the use of bracing for AIS.  Bracing is appropriate for idiopathic curves between 20 and 40, with successful control of these curves reported in >70% of patients.  Patient adherence to the prescribed duration of wear is essential to maximize the effectiveness of the brace.  The choice of brace type must be individualized according to the deformity and the patient's personality as well as the practice setting and brace availability."  As per Menger & Sin (2019), "Those with curves greater than 25 degrees but less than 40 to 45 degrees are candidates for bracing.  The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) was an NIH funded randomized control trial that illustrated the effectiveness of bracing in the adolescent population."  The device and concept is Food and Drug Administration (FDA) approved. 

Based upon the review of the medical record and literature, this patient is a good candidate for bracing.  The use of bracing for this patient with a diagnosis of adolescent idiopathic scoliosis is appropriate. 

Therefore, the requested service, self-operated spinal unloading device; code L1499 is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of a back device (self-operated spinal unloading device; code L1499) should be reversed.