Guest guest Posted September 24, 2009 Report Share Posted September 24, 2009 Oh happy day - just had to share. My little got his Starband a few weeks ago. When we went for the consult, we were told insurance would not cover it - which we knew going in because he was 12 1/2 months old and per Aetna's policy bulletins, they don't cover over age 12 months. He fit all other criteria. Nick has a host of other issues as well stemming from a blood clot and brain surgery after birth, so with the brain damage has microcephaly. I made the appeal with support from his ped, PT and nuerosurgeon that he still had a lot of growth in his head and whereas he might wear the band longer, we should see results. I sent in 18 pages of letters of medical necessity, an appeal letter from us (main body included below), copies of articles referenced, etc. Just checked the EOB status online and it says they are covering it 100% - no co pay, no deductible, nothing. From the info I have it says DME is covered but with a $30 co pay - they are not even making me pay that, but then again, it doesn't say that it is being billed as DME but says medical supplies or something like that so maybe that is the difference. We knew we were starting with Nick late and fully expected to pay out of pocket, so this is a nice surprise. Keep trying for the others that are appealing - good luck. Angie Dear Appeals Resolution Team: RE: DCN# We respectfully request that you review and reconsider coverage of a cranial remolding orthosis for our son, B (DOB ). It appears, from the letter I received dated 7-30-2009 (DCN#), that the denial for coverage is based on ’ age [Aetna considers a cranial remodeling orthosis to be not medically necessary when banding is initiated after 12 months of age.] since the other criteria listed in the Clinical Policy Bulletin number 0379 include a difference of asymmetry great than 6 mm between anthropometric measurements (of which measures 13 mm Cranial Vault Asymmetry) and a Cephalic Index +2 standard deviations above the mean, which in the chart lists 91.2 for a male (of which was measured at 93). Due to ’ time spent in the NICU, his torticollis, his developmental delays which have increased his plagiocephaly since he cannot yet sit unassisted, and his slow head growth, we are in agreement with the Physical Therapist (Deanne Hilvert), Neurosurgeon (Bakhtiar Yamini), Pediatrician (Mely Tan) and the Orthotists at Scheck & Siress that will still benefit from such a device despite his advanced age. A little background on the device chosen and the issues surrounding need for a cranial remodeling orthosis: Cause of Head Shape Deformities Intrinsic factors can pre-dispose a baby to extrinsic abnormal molding of the skull due to medical issues, procedures or delays that cause the baby’s head to rest in one position.1 Extrinsic factors that contribute to skull deformities are well documented as well (torticollis). Post-natal extrinsic factors can also affect the newborn skull as seen in . . . babies who require prolonged hospitalization until they are medically stable. Term and preterm infants may develop abnormal head shapes “due to medical treatment, nursing care practices, positioning limitation and underlying muscle tone abnormalities.†2 Significant univariate risk factors of nonsynostotic plagiocephaly include: limited passive neck rotation at birth, preferential head orientation, supine sleep position, limited active head rotation at 4 months, lower activity level, and developmental delay and trying unsuccessfully to vary head position when putting the infant down to sleep.3 Alternative Treatments We have used aggressive repositioning therapies with since he was two months old. He is seeing a Physical Therapist twice weekly (with a third weekly session to be added) for torticollis, in addition to his gross motor delays. Since has low tone in his trunk and cannot sit unassisted, we have used a Bumbo seat and low back seat to support in an upright position as much as possible. We have been advised and taught proper “tummy time†techniques since his release from the University of Chicago Comer Children’s Hospital and have used tummy time plus supine positioning for several months to no avail. Studies recommend that infants with mild deformities without other compounding features be monitored, repositioned and provided with frequent prone activities during the day (we have done this). They recommend that infants with moderate to severe deformities be treated with custom cranial remodeling orthoses if efforts at therapy and/or repositioning fail to correct the deformity. 1 Therapy has been initiated for neck tightness, weakness and developmental delays that have not resolved on their own. STAR Cranial Remolding Orthoses STARTM Cranial Remolding Orthoses derive their name from their purpose – Symmetry Through Active Remolding. These custom orthoses are fabricated from an exact model of the infant’s cranium to obtain optimum fit and function. The rigid outer shell maintains the structural design integrity and is either lined with closed cell foam to allow progressive adjustments (this describes ’ band) or is made of a clear thermo-plastic material which allows easy visual inspection of the areas of contact and voids within the orthosis. The STARband is modified throughout the treatment program to accommodate growth, promote symmetry, and improve proportion. 1 STAR Cranial Remolding Orthosis Treatment The STAR treatment program focuses on redirecting cranial growth toward great symmetry and proportion. This is accomplished by maintaining contact over the areas of bossing and allowing room for growth inside the orthosis in the areas where the infant’s skull is depressed or flattened. The practitioner makes progressive adjustments through multiple appointments over the course of the treatment program to accommodate and direct skull growth into a more symmetrical and well-proportioned shape. Unlike prefabricated helmets that come in only two sizes, custom STAR Cranial Remolding Orthoses are uniquely designed for each infant to hold key areas of the skull and limit abnormal/asymmetrical vertex height and diagonals, and normalize the shape of the parietal and frontal bones. 1 Treatment of the Older Infant Infants older than twelve months may require a longer treatment program due to the normal decrease in skull growth after this time and the increased thickness and rigidity of the cranium. Research indicates that the greatest symmetry can be attained through early intervention, but some correction is still possible in infants up to 18 months of age.1 Through a series of case reports, evidence has been presented that this treatment remains viable during the second year of life and that improvement has been observed in infants in whom treatment has been initiated as late as 18 months.4 It has generally been believed that increasing cranial rigidity and decreasing cranial growth prohibit orthotic treatment in infants older than one year of age. However, as awareness of positional plagiocephaly has become more widespread and access to treatment more readily available, increasing numbers of older infants are presenting for evaluation. Although older infants still continue to represent only a small proportion of the treatment population, treatment results have been promising and, through a series of case reports, evidence has presented suggesting that this treatment modality remains viable will into the second year of life. 4 Additional information presented in case studies states that helmet therapy is generally recommended between 6 and 18 months of age in an attempt to use remaining brain growth to redirect head shape.1 ’ microcephaly leaves much room for future brain growth, even in his advanced age in the helmet. Reducing the Effects of Head Shape Deformities and Untreated Plagiocephaly The STAR Cranial Remolding Orthoses allows the infant’s head to turn more freely instead of resting on the flattened area of the occiput. This facilitates the development of more advanced motor skills. The orthosis also provides space in the affected flattened areas to prevent further deformity at night when the baby is supine and when the infant is positioned for protection in the car seat. In both of these positions, the infant has more neck mobility in the STAR orthosis because the more rounded occipital area allows symmetrical turning and midline positioning.1 This is very important in ’ case since he still cannot sit unassisted and spends a great deal of time in a supine position. There is also clinical evidence that prior to intervention, babies with deformational plagiocephaly may have developmental issues, visual tracking problems and strabismus, mandibular asymmetry and auditory issues:1 - Infants with deformational plagiocephaly comprise a high-risk group of developmental difficulties. 5 - Children with deformational plagiocephaly are at an increased risk for developmental problems specifically in the area of verbal communication skills. 6 - Sound processing at the cortical level, as reflected by ERP’s, is affected in many of the children with plagiocephaly. Infants with plagiocephaly may comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. 7 In summary, we are convinced that a cranial remolding orthotic is the most well-documented and successful treatment program to provide non-invasive intervention that will positively impact ’ development for a lifetime. As his pediatrician noted, “he needs a cranial helmet to help correct the problem and maximize his developmental potential without having to resort to future expensive and risky surgery.†8 ’ neurosurgeon recommends the molding helmet even at his advanced age because ’ plagiocephaly is significant and his fontanelle is still open. 9 Finally, per the letter of medical necessity submitted by his Physical Therapist, “Although is 12 months old, he will benefit from orthotic treatment due to his unique developmental and medical history including Neurosurgery. He still has growth and mobility available in his cranium which is an important factor to consider when deciding on orthotic treatment. He can still achieve corrected cranial alignment.†10 Aetna is a company that has proven itself to be a leader in proactive management of health and well being. Members have learning resources, online tools and a vast library of information available to them to make wise decisions about their health. Aetna’s mission and values are consistent with that of a leader in the industry, and it is no surprise Aetna was named FORTUNE Magazine’s most admired company in the Health Care: Insurance and Managed Care category for the second year in a row. It is also no surprise that Aetna was ranked first among national health plans in the 2008 PayerView Rankings, as a company that pays physicians faster and denies claims less often than other health plans measured. For all of these reasons, we respectfully request that you reexamine the long-term benefits of the cranial remolding device for Burton despite his advanced age. The documented risks associated with untreated plagiocephaly, coupled with ’ neurological history, support the STARband helmet as a proven successful, non-invasive treatment program. Thank you for your consideration of our appeal. Respectfully, 1 Lima, Dulcy, CO, OTR/L. Orthotic Management of Pediatric Cranial Deformities Using STAR Cranial Remolding Orthoses 2 Hummell, P, Fortado D. Impacting Infant Head Shapes. Advances in Neonatal Care. 2005, 5:6:320-340. 3 Hutchinson, Lynne, Hutchinson Luke, , , , Ed. Plagiocephaly and Brachycephaly in the First Two Years of Life: A Prospective Cohort Study. Pediatrics Vol 114 No 4, October 2004, 970-980. 4 Littlefield TR, Pomatto JK, KM. Dynamic Orthotic Cranioplasty: Treatment of the Older Infant. Neurosurgical Focus 2000; 53:367-377. 5 RI., Clarren M.D. Long-Term Developmental Outcomes in Patients with Deformational Pagiocephaly. Pediatrics 2000, 5 (2/e26): 1-5. 6 Aregenta, L, , LR, Goldstein D, & Kilgo P. Long Term Developmental Outcomes in Children With Deformational Plagiocephaly. Craniofacial Surgery VI 2001: 65-67. 7 Balan P, Kushnerenko E, Sahlin P, Huotilainen M, Naatanen R, Hukki, J. Auditory ERP’s Reveal Brain Dysfunction in Infants with Plagiocephaly. 8 Dr. Mely Tan, Pediatrician – letter 9 Dr. Bakhtiar Yamini, MD, Assistant Professor Pediatric Neurosurgery – letter 10 Deanne Hilvert, PT – letter Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 24, 2009 Report Share Posted September 24, 2009 That's great news! We also had Aetna and my daughter's Starband was covered 100%. > > > Oh happy day - just had to share. >  > My little got his Starband a few weeks ago. When we went for the consult, we were told insurance would not cover it - which we knew going in because he was 12 1/2 months old and per Aetna's policy bulletins, they don't cover over age 12 months. He fit all other criteria. >  > Nick has a host of other issues as well stemming from a blood clot and brain surgery after birth, so with the brain damage has microcephaly. I made the appeal with support from his ped, PT and nuerosurgeon that he still had a lot of growth in his head and whereas he might wear the band longer, we should see results. I sent in 18 pages of letters of medical necessity, an appeal letter from us (main body included below), copies of articles referenced, etc. Just checked the EOB status online and it says they are covering it 100% - no co pay, no deductible, nothing. From the info I have it says DME is covered but with a $30 co pay - they are not even making me pay that, but then again, it doesn't say that it is being billed as DME but says medical supplies or something like that so maybe that is the difference. >  > We knew we were starting with Nick late and fully expected to pay out of pocket, so this is a nice surprise. Keep trying for the others that are appealing - good luck. >  > Angie >  >  >  >  > Dear Appeals Resolution Team: >  > RE: DCN# >  > We respectfully request that you review and reconsider coverage of a cranial remolding orthosis for our son, B (DOB ). >  > It appears, from the letter I received dated 7-30-2009 (DCN#), that the denial for coverage is based on ’ age [Aetna considers a cranial remodeling orthosis to be not medically necessary when banding is initiated after 12 months of age.]  since the other criteria listed in the Clinical Policy Bulletin number 0379 include a difference of asymmetry great than 6 mm between anthropometric measurements (of which measures 13 mm Cranial Vault Asymmetry) and a Cephalic Index +2 standard deviations above the mean, which in the chart lists 91.2 for a male (of which was measured at 93). >  > Due to ’ time spent in the NICU, his torticollis, his developmental delays which have increased his plagiocephaly since he cannot yet sit unassisted, and his slow head growth, we are in agreement with the Physical Therapist (Deanne Hilvert), Neurosurgeon (Bakhtiar Yamini), Pediatrician (Mely Tan) and the Orthotists at Scheck & Siress that will still benefit from such a device despite his advanced age. >  > A little background on the device chosen and the issues surrounding need for a cranial remodeling orthosis: >  > Cause of Head Shape Deformities > Intrinsic factors can pre-dispose a baby to extrinsic abnormal molding of the skull due to medical issues, procedures or delays that cause the baby’s head to rest in one position.1 Extrinsic factors that contribute to skull deformities are well documented as well (torticollis). Post-natal extrinsic factors can also affect the newborn skull as seen in . . . babies who require prolonged hospitalization until they are medically stable. Term and preterm infants may develop abnormal head shapes “due to medical treatment, nursing care practices, positioning limitation and underlying muscle tone abnormalities.†2 Significant univariate risk factors of nonsynostotic plagiocephaly include: limited passive neck rotation at birth, preferential head orientation, supine sleep position, limited active head rotation at 4 months, lower activity level, and developmental delay and trying unsuccessfully to vary head position when putting the infant down to > sleep.3 >  > Alternative Treatments > We have used aggressive repositioning therapies with since he was two months old. He is seeing a Physical Therapist twice weekly (with a third weekly session to be added) for torticollis, in addition to his gross motor delays. Since has low tone in his trunk and cannot sit unassisted, we have used a Bumbo seat and low back seat to support in an upright position as much as possible. We have been advised and taught proper “tummy time†techniques since his release from the University of Chicago Comer Children’s Hospital and have used tummy time plus supine positioning for several months to no avail. Studies recommend that infants with mild deformities without other compounding features be monitored, repositioned and provided with frequent prone activities during the day (we have done this). They recommend that infants with moderate to severe deformities be treated with custom cranial remodeling orthoses if efforts at > therapy and/or repositioning fail to correct the deformity. 1 Therapy has been initiated for neck tightness, weakness and developmental delays that have not resolved on their own. > >  >  > STAR Cranial Remolding Orthoses > STARTM Cranial Remolding Orthoses derive their name from their purpose †" Symmetry Through Active Remolding. These custom orthoses are fabricated from an exact model of the infant’s cranium to obtain optimum fit and function. The rigid outer shell maintains the structural design integrity and is either lined with closed cell foam to allow progressive adjustments (this describes ’ band) or is made of a clear thermo-plastic material which allows easy visual inspection of the areas of contact and voids within the orthosis. The STARband is modified throughout the treatment program to accommodate growth, promote symmetry, and improve proportion. 1 >  > STAR Cranial Remolding Orthosis Treatment > The STAR treatment program focuses on redirecting cranial growth toward great symmetry and proportion. This is accomplished by maintaining contact over the areas of bossing and allowing room for growth inside the orthosis in the areas where the infant’s skull is depressed or flattened. The practitioner makes progressive adjustments through multiple appointments over the course of the treatment program to accommodate and direct skull growth into a more symmetrical and well-proportioned shape. Unlike prefabricated helmets that come in only two sizes, custom STAR Cranial Remolding Orthoses are uniquely designed for each infant to hold key areas of the skull and limit abnormal/asymmetrical vertex height and diagonals, and normalize the shape of the parietal and frontal bones. 1 >  > Treatment of the Older Infant > Infants older than twelve months may require a longer treatment program due to the normal decrease in skull growth after this time and the increased thickness and rigidity of the cranium. Research indicates that the greatest symmetry can be attained through early intervention, but some correction is still possible in infants up to 18 months of age.1 Through a series of case reports, evidence has been presented that this treatment remains viable during the second year of life and that improvement has been observed in infants in whom treatment has been initiated as late as 18 months.4 It has generally been believed that increasing cranial rigidity and decreasing cranial growth prohibit orthotic treatment in infants older than one year of age. However, as awareness of positional plagiocephaly has become more widespread and access to treatment more readily available, increasing numbers of older infants are presenting for evaluation. Although older infants > still continue to represent only a small proportion of the treatment population, treatment results have been promising and, through a series of case reports, evidence has presented suggesting that this treatment modality remains viable will into the second year of life. 4  Additional information presented in case studies states that helmet therapy is generally recommended between 6 and 18 months of age in an attempt to use remaining brain growth to redirect head shape.1 ’ microcephaly leaves much room for future brain growth, even in his advanced age in the helmet. >  > Reducing the Effects of Head Shape Deformities and Untreated Plagiocephaly > The STAR Cranial Remolding Orthoses allows the infant’s head to turn more freely instead of resting on the flattened area of the occiput. This facilitates the development of more advanced motor skills. The orthosis also provides space in the affected flattened areas to prevent further deformity at night when the baby is supine and when the infant is positioned for protection in the car seat. In both of these positions, the infant has more neck mobility in the STAR orthosis because the more rounded occipital area allows symmetrical turning and midline positioning.1  This is very important in ’ case since he still cannot sit unassisted and spends a great deal of time in a supine position. >  > There is also clinical evidence that prior to intervention, babies with deformational plagiocephaly may have developmental issues, visual tracking problems and strabismus, mandibular asymmetry and auditory issues:1  > -         Infants with deformational plagiocephaly comprise a high-risk group of developmental difficulties. 5 > -         Children with deformational plagiocephaly are at an increased risk for developmental problems specifically in the area of verbal communication skills. 6 > -         Sound processing at the cortical level, as reflected by ERP’s, is affected in many of the children with plagiocephaly. Infants with plagiocephaly may comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. 7 >  >  >  > In summary, we are convinced that a cranial remolding orthotic is the most well-documented and successful treatment program to provide non-invasive intervention that will positively impact ’ development for a lifetime. As his pediatrician noted, “he needs a cranial helmet to help correct the problem and maximize his developmental potential without having to resort to future expensive and risky surgery.†8   ’ neurosurgeon recommends the molding helmet even at his advanced age because ’ plagiocephaly is significant and his fontanelle is still open. 9  Finally, per the letter of medical necessity submitted by his Physical Therapist, “Although is 12 months old, he will benefit from orthotic treatment due to his unique developmental and medical history including Neurosurgery. He still has growth and mobility available in his cranium which is an important factor to consider when deciding on orthotic treatment. > He can still achieve corrected cranial alignment.†10 >  > Aetna is a company that has proven itself to be a leader in proactive management of health and well being. Members have learning resources, online tools and a vast library of information available to them to make wise decisions about their health. Aetna’s mission and values are consistent with that of a leader in the industry, and it is no surprise Aetna was named FORTUNE Magazine’s most admired company in the Health Care: Insurance and Managed Care category for the second year in a row. It is also no surprise that Aetna was ranked first among national health plans in the 2008 PayerView Rankings, as a company that pays physicians faster and denies claims less often than other health plans measured. For all of these reasons, we respectfully request that you reexamine the long-term benefits of the cranial remolding device for Burton despite his advanced age. The documented risks associated with untreated plagiocephaly, coupled with ’ > neurological history, support the STARband helmet as a proven successful, non-invasive treatment program. >  > Thank you for your consideration of our appeal. >  > Respectfully, >  >  >  > >  > >  >  > 1 Lima, Dulcy, CO, OTR/L. Orthotic Management of Pediatric Cranial Deformities Using STAR Cranial Remolding Orthoses >  > 2 Hummell, P, Fortado D. Impacting Infant Head Shapes. Advances in Neonatal Care. 2005, 5:6:320-340. >  > 3 Hutchinson, Lynne, Hutchinson Luke, , , , Ed. Plagiocephaly and Brachycephaly in the First Two Years of Life: A Prospective Cohort Study. Pediatrics Vol 114 No 4, October 2004, 970-980. >  > 4 Littlefield TR, Pomatto JK, KM. Dynamic Orthotic Cranioplasty: Treatment of the Older Infant. Neurosurgical Focus 2000; 53:367-377. >  > 5 RI., Clarren M.D. Long-Term Developmental Outcomes in Patients with Deformational Pagiocephaly. Pediatrics 2000, 5 (2/e26): 1-5. >  > 6 Aregenta, L, , LR, Goldstein D, & Kilgo P. Long Term Developmental Outcomes in Children With Deformational Plagiocephaly. Craniofacial Surgery VI 2001: 65-67. >  > 7 Balan P, Kushnerenko E, Sahlin P, Huotilainen M, Naatanen R, Hukki, J. Auditory ERP’s Reveal Brain Dysfunction in Infants with Plagiocephaly. >  > 8 Dr. Mely Tan, Pediatrician †" letter >  > 9 Dr. Bakhtiar Yamini, MD, Assistant Professor Pediatric Neurosurgery †" letter >  > 10 Deanne Hilvert, PT †" letter >  >  >  > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 25, 2009 Report Share Posted September 25, 2009  Congratulations on winning your appeal. Please keep us updated on how Nick is doing. Angie Happy Day - appeal won! Oh happy day - just had to share. My little got his Starband a few weeks ago. When we went for the consult, we were told insurance would not cover it - which we knew going in because he was 12 1/2 months old and per Aetna's policy bulletins, they don't cover over age 12 months. He fit all other criteria. Nick has a host of other issues as well stemming from a blood clot and brain surgery after birth, so with the brain damage has microcephaly. I made the appeal with support from his ped, PT and nuerosurgeon that he still had a lot of growth in his head and whereas he might wear the band longer, we should see results. I sent in 18 pages of letters of medical necessity, an appeal letter from us (main body included below), copies of articles referenced, etc. Just checked the EOB status online and it says they are covering it 100% - no co pay, no deductible, nothing. From the info I have it says DME is covered but with a $30 co pay - they are not even making me pay that, but then again, it doesn't say that it is being billed as DME but says medical supplies or something like that so maybe that is the difference. We knew we were starting with Nick late and fully expected to pay out of pocket, so this is a nice surprise. Keep trying for the others that are appealing - good luck. Angie Dear Appeals Resolution Team: RE: DCN# We respectfully request that you review and reconsider coverage of a cranial remolding orthosis for our son, B (DOB ). It appears, from the letter I received dated 7-30-2009 (DCN#), that the denial for coverage is based on ’ age [Aetna considers a cranial remodeling orthosis to be not medically necessary when banding is initiated after 12 months of age.] since the other criteria listed in the Clinical Policy Bulletin number 0379 include a difference of asymmetry great than 6 mm between anthropometric measurements (of which measures 13 mm Cranial Vault Asymmetry) and a Cephalic Index +2 standard deviations above the mean, which in the chart lists 91.2 for a male (of which was measured at 93). Due to ’ time spent in the NICU, his torticollis, his developmental delays which have increased his plagiocephaly since he cannot yet sit unassisted, and his slow head growth, we are in agreement with the Physical Therapist (Deanne Hilvert), Neurosurgeon (Bakhtiar Yamini), Pediatrician (Mely Tan) and the Orthotists at Scheck & Siress that will still benefit from such a device despite his advanced age. A little background on the device chosen and the issues surrounding need for a cranial remodeling orthosis: Cause of Head Shape Deformities Intrinsic factors can pre-dispose a baby to extrinsic abnormal molding of the skull due to medical issues, procedures or delays that cause the baby’s head to rest in one position.1 Extrinsic factors that contribute to skull deformities are well documented as well (torticollis). Post-natal extrinsic factors can also affect the newborn skull as seen in . . . babies who require prolonged hospitalization until they are medically stable. Term and preterm infants may develop abnormal head shapes “due to medical treatment, nursing care practices, positioning limitation and underlying muscle tone abnormalities.†2 Significant univariate risk factors of nonsynostotic plagiocephaly include: limited passive neck rotation at birth, preferential head orientation, supine sleep position, limited active head rotation at 4 months, lower activity level, and developmental delay and trying unsuccessfully to vary head position when putting the infant down to sleep.3 Alternative Treatments We have used aggressive repositioning therapies with since he was two months old. He is seeing a Physical Therapist twice weekly (with a third weekly session to be added) for torticollis, in addition to his gross motor delays. Since has low tone in his trunk and cannot sit unassisted, we have used a Bumbo seat and low back seat to support in an upright position as much as possible. We have been advised and taught proper “tummy time†techniques since his release from the University of Chicago Comer Children’s Hospital and have used tummy time plus supine positioning for several months to no avail. Studies recommend that infants with mild deformities without other compounding features be monitored, repositioned and provided with frequent prone activities during the day (we have done this). They recommend that infants with moderate to severe deformities be treated with custom cranial remodeling orthoses if efforts at therapy and/or repositioning fail to correct the deformity. 1 Therapy has been initiated for neck tightness, weakness and developmental delays that have not resolved on their own. STAR Cranial Remolding Orthoses STARTM Cranial Remolding Orthoses derive their name from their purpose – Symmetry Through Active Remolding. These custom orthoses are fabricated from an exact model of the infant’s cranium to obtain optimum fit and function. The rigid outer shell maintains the structural design integrity and is either lined with closed cell foam to allow progressive adjustments (this describes ’ band) or is made of a clear thermo-plastic material which allows easy visual inspection of the areas of contact and voids within the orthosis. The STARband is modified throughout the treatment program to accommodate growth, promote symmetry, and improve proportion. 1 STAR Cranial Remolding Orthosis Treatment The STAR treatment program focuses on redirecting cranial growth toward great symmetry and proportion. This is accomplished by maintaining contact over the areas of bossing and allowing room for growth inside the orthosis in the areas where the infant’s skull is depressed or flattened. The practitioner makes progressive adjustments through multiple appointments over the course of the treatment program to accommodate and direct skull growth into a more symmetrical and well-proportioned shape. Unlike prefabricated helmets that come in only two sizes, custom STAR Cranial Remolding Orthoses are uniquely designed for each infant to hold key areas of the skull and limit abnormal/asymmetrical vertex height and diagonals, and normalize the shape of the parietal and frontal bones. 1 Treatment of the Older Infant Infants older than twelve months may require a longer treatment program due to the normal decrease in skull growth after this time and the increased thickness and rigidity of the cranium. Research indicates that the greatest symmetry can be attained through early intervention, but some correction is still possible in infants up to 18 months of age.1 Through a series of case reports, evidence has been presented that this treatment remains viable during the second year of life and that improvement has been observed in infants in whom treatment has been initiated as late as 18 months.4 It has generally been believed that increasing cranial rigidity and decreasing cranial growth prohibit orthotic treatment in infants older than one year of age. However, as awareness of positional plagiocephaly has become more widespread and access to treatment more readily available, increasing numbers of older infants are presenting for evaluation. Although older infants still continue to represent only a small proportion of the treatment population, treatment results have been promising and, through a series of case reports, evidence has presented suggesting that this treatment modality remains viable will into the second year of life. 4 Additional information presented in case studies states that helmet therapy is generally recommended between 6 and 18 months of age in an attempt to use remaining brain growth to redirect head shape.1 ’ microcephaly leaves much room for future brain growth, even in his advanced age in the helmet. Reducing the Effects of Head Shape Deformities and Untreated Plagiocephaly The STAR Cranial Remolding Orthoses allows the infant’s head to turn more freely instead of resting on the flattened area of the occiput. This facilitates the development of more advanced motor skills. The orthosis also provides space in the affected flattened areas to prevent further deformity at night when the baby is supine and when the infant is positioned for protection in the car seat. In both of these positions, the infant has more neck mobility in the STAR orthosis because the more rounded occipital area allows symmetrical turning and midline positioning.1 This is very important in ’ case since he still cannot sit unassisted and spends a great deal of time in a supine position. There is also clinical evidence that prior to intervention, babies with deformational plagiocephaly may have developmental issues, visual tracking problems and strabismus, mandibular asymmetry and auditory issues:1 - Infants with deformational plagiocephaly comprise a high-risk group of developmental difficulties. 5 - Children with deformational plagiocephaly are at an increased risk for developmental problems specifically in the area of verbal communication skills. 6 - Sound processing at the cortical level, as reflected by ERP’s, is affected in many of the children with plagiocephaly. Infants with plagiocephaly may comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. 7 In summary, we are convinced that a cranial remolding orthotic is the most well-documented and successful treatment program to provide non-invasive intervention that will positively impact ’ development for a lifetime. As his pediatrician noted, “he needs a cranial helmet to help correct the problem and maximize his developmental potential without having to resort to future expensive and risky surgery.†8 ’ neurosurgeon recommends the molding helmet even at his advanced age because ’ plagiocephaly is significant and his fontanelle is still open. 9 Finally, per the letter of medical necessity submitted by his Physical Therapist, “Although is 12 months old, he will benefit from orthotic treatment due to his unique developmental and medical history including Neurosurgery. He still has growth and mobility available in his cranium which is an important factor to consider when deciding on orthotic treatment. He can still achieve corrected cranial alignment.†10 Aetna is a company that has proven itself to be a leader in proactive management of health and well being. Members have learning resources, online tools and a vast library of information available to them to make wise decisions about their health. Aetna’s mission and values are consistent with that of a leader in the industry, and it is no surprise Aetna was named FORTUNE Magazine’s most admired company in the Health Care: Insurance and Managed Care category for the second year in a row. It is also no surprise that Aetna was ranked first among national health plans in the 2008 PayerView Rankings, as a company that pays physicians faster and denies claims less often than other health plans measured. For all of these reasons, we respectfully request that you reexamine the long-term benefits of the cranial remolding device for Burton despite his advanced age. The documented risks associated with untreated plagiocephaly, coupled with ’ neurological history, support the STARband helmet as a proven successful, non-invasive treatment program. Thank you for your consideration of our appeal. Respectfully, 1 Lima, Dulcy, CO, OTR/L. Orthotic Management of Pediatric Cranial Deformities Using STAR Cranial Remolding Orthoses 2 Hummell, P, Fortado D. Impacting Infant Head Shapes. Advances in Neonatal Care. 2005, 5:6:320-340. 3 Hutchinson, Lynne, Hutchinson Luke, , , , Ed. Plagiocephaly and Brachycephaly in the First Two Years of Life: A Prospective Cohort Study. Pediatrics Vol 114 No 4, October 2004, 970-980. 4 Littlefield TR, Pomatto JK, KM. Dynamic Orthotic Cranioplasty: Treatment of the Older Infant. Neurosurgical Focus 2000; 53:367-377. 5 RI., Clarren M.D. Long-Term Developmental Outcomes in Patients with Deformational Pagiocephaly. Pediatrics 2000, 5 (2/e26): 1-5. 6 Aregenta, L, , LR, Goldstein D, & Kilgo P. Long Term Developmental Outcomes in Children With Deformational Plagiocephaly. Craniofacial Surgery VI 2001: 65-67. 7 Balan P, Kushnerenko E, Sahlin P, Huotilainen M, Naatanen R, Hukki, J. Auditory ERP’s Reveal Brain Dysfunction in Infants with Plagiocephaly. 8 Dr. Mely Tan, Pediatrician – letter 9 Dr. Bakhtiar Yamini, MD, Assistant Professor Pediatric Neurosurgery – letter 10 Deanne Hilvert, PT – letter Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 26, 2009 Report Share Posted September 26, 2009 That is awesome Angie! Thanks for posting the letter too! Jen Mom to Luli - 3 yrs old Torticollis, Plagio, Syringomyelia Happy Day - appeal won! Oh happy day - just had to share. My little got his Starband a few weeks ago. When we went for the consult, we were told insurance would not cover it - which we knew going in because he was 12 1/2 months old and per Aetna's policy bulletins, they don't cover over age 12 months. He fit all other criteria. =0 ANick has a host of other issues as well stemming from a blood clot and brain surgery after birth, so with the brain damage has microcephaly. I made the appeal with support from his ped, PT and nuerosurgeon that he still had a lot of growth in his head and whereas he might wear the band longer, we should see results. I sent in 18 pages of letters of medical necessity, an appeal letter from us (main body included below), copies of articles referenced, etc. Just checked the EOB status online and it says they are covering it 100% - no co pay, no deductible, nothing. From the info I have it says DME is covered but with a $30 co pay - they are not even making me pay that, but then again, it doesn't say that it is being billed as DME but says medical supplies or something like that so maybe that is the difference. We knew we were starting with Nick late and fully expected to pay out of pocket, so this is a nice surprise. Keep trying for the others that are appealing - good luck. Angie Dear Appeals Resolution Team: RE: DCN# We respectfully request that you review and reconsider coverage of a cranial remolding orthosis for our son, B (DOB ). It appears, from the letter I received dated 7-30-2009 (DCN#), that the denial for coverage is based on ’ age [Aetna considers a cranial remodeling orthosis to be not medically necessary when banding is initiated after 12 months of age.] since the other criteria listed in the Clinical Policy Bulletin number 0379 include a difference of asymmetry great than 6 mm between anthropometric measurements (of which measures 13 mm Cranial Vault Asymmetry) and a Cephalic Index +2 standard deviations above the mean, which in the chart lists 91.2 for a male (of which was measured at 93). Due to ’ time spent in the NICU, his torticollis, his developmental delays which have increased his plagiocephaly since he cannot yet sit unassisted, and his slow head growth, we are in agreement with the Physical Therapist (Deanne Hilvert), Neurosurgeon (Bakhtiar Yamini), Pediatrician (Mely Tan) and the Orthotists at Scheck & Siress that will still benefit from such a device despite his advanced age. A little background on the device chosen and the issues surrounding need for a cranial remodeling orthosis: Cause of Head Shape Deformities Intrinsic factors can pre-dispose a baby to extrinsic abnormal molding of the skull due to medical issues, procedures or delays that cause the baby’s head to rest in one position.1 Extrinsic factors that contribute to skull deformities are well documented as well (torticollis). Post-natal extrinsic factors can also affect the newborn skull as seen in . . . babies who require prolonged hospitalization until they are medically stable. Term and preterm infants may develop abnormal head shapes “due to medical treatment, nursing care practices, positioning limitation and underlying muscle tone abnormalities.†2 Significant univariate risk factors of nonsynostotic plagiocephaly include: limited passive neck rotation at birth, preferential head orientation, supine sleep position, limited active head rotation at 4 months, lower activity level, and developmental delay and trying unsuccessfully to vary head position when putting the infant down to sleep.3 Alternative Treatments We have used aggressive repositioning therapies with since he was two months old. He is seeing a Physical Therapist twice weekly (with a third weekly session to be added) for torticollis, in addition to his gross motor delays. Since has low tone in his trunk and cannot sit unassisted, we have used a Bumbo seat and low back seat to support in an upright position as much as possible. We have been advised and taught proper “tummy time†techniques since his release from the University of Chicago Comer Children’s Hospital and have used tummy time plus supine positioning for several months to no avail. Studies recommend that infants with mild deformities without other compounding features be monitored, repositioned and provided with frequent prone activities during the day (we have done this). They recommend that infants with moderate to severe deformities be treated with custom cranial remodeling orthoses if efforts at therapy and/or repositioning fail to correct the deformity. 1 Therapy has been initiated for neck tightness, weakness and developmental delays that have not resolved on their own. STAR Cranial Remolding Orthoses =0 A STARTM Cranial Remolding Orthoses derive their name from their purpose – Symmetry Through Active Remolding. These custom orthoses are fabricated from an exact model of the infant’s cranium to obtain optimum fit and function. The rigid outer shell maintains the structural design integrity and is either lined with closed cell foam to allow progressive adjustments (this describes ’ band) or is made of a clear thermo-plastic material which allows easy visual inspection of the areas of contact and voids within the orthosis. The STARband is modified throughout the treatment program to accommodate growth, promote symmetry, and improve proportion. 1 STAR Cranial Remolding Orthosis Treatment The STAR treatment program focuses on redirecting cranial growth toward great symmetry and proportion. This is accomplished by maintaining contact over the areas of bossing and allowing room for growth inside the orthosis in the areas where the infant’s skull is depressed or flattened. The practitioner makes progressive adjustments through multiple appointments over the course of the treatment program to accommodate and direct skull growth into a more symmetrical and well-proportioned shape. Unlike prefabricated helmets that come in only two sizes, custom STAR Cranial Remolding Orthoses are uniquely designed for each infant to hold key areas of the skull and limit abnormal/asymmetrical vertex height and diagonals, and normalize the shape of the parietal and frontal bones. 1 Treatment of the Older Infant Infants older than twelve months may require a longer treatment program due to the normal decrease in skull growth after this time and the increased thickness and rigidity of the cranium. Research indicates that the greatest symmetry can be attained through early intervention, but some correction is still possible in infants up to 18 months of age.1 Through a series of case reports, evidence has been presented that this treatment remains viable during the second year of life and that improvement has been observed in infants in whom treatment has been initiated as late as 18 months.4 It has generally been believed that increasing cranial rigidity and decreasing cranial growth prohibit orthotic treatment in infants older than one year of age. However, as awareness of positional plagiocephaly has become more widespread and access to treatment more readily available, increasing numbers of older infants are presenting for evaluation. Although older infants still continue to represent only a small proportion of the treatment population, treatment results have been promi sing and, through a series of case reports, evidence has presented suggesting that this treatment modality remains viable will into the second year of life. 4 Additional information presented in case studies states that helmet therapy is generally recommended between 6 and 18 months of age in an attempt to use remaining brain growth to redirect head shape.1 ’ microcephaly leaves much room for future brain growth, even in his advanced age in the helmet. Reducing the Effects of Head Shape Deformities and Untreated Plagiocephaly The STAR Cranial Remolding Orthoses allows the infant’s head to turn more freely instead of resting on the flattened area of the occiput. This facilitates the development of more advanced motor skills. The orthosis also provides space in the affected flattened areas to prevent further deformity at night when the baby is supine and when the infant is positioned for protection in the car seat. In both of these positions, the infant has more neck mobility in the STAR orthosis because the more rounded occipital area allows symmetrical turning and midline positioning.1 This is very important in ’ case since he still cannot sit unassisted and spends a great deal of time in a supine position. nbsp; There is also clinical evidence that prior to intervention, babies with deformational plagiocephaly may have developmental issues, visual tracking problems and strabismus, mandibular asymmetry and auditory issues:1 - Infants with deformational plagiocephaly comprise a high-risk group of developmental difficulties. 5 - Children with deformational plagiocephaly are at an increased risk for developmental problems specifically in the area of verbal communication skills. 6 - Sound processing at the cortical level, as reflected by ERP’s, is affected in many of the children with plagiocephaly. Infants with plagiocephaly may comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. 7 In summary, we are convinced that a cranial remolding orthotic is the most well-documented and successful treatment program to provide non-invasive intervention that will positively impact ’ development for a lifetime. As his pediatrician noted, “he needs a cranial helmet to help correct the problem and maximize his developmental potential without having to resort to future expensive and risky surgery.†8 ’ neurosurgeon recommends the molding helmet even at his advanced age because ’ plagiocephaly is significant and his fontanelle is still open. 9 Finally, per the letter of medical necessity submitted by his Physical Therapist, “Although is 12 months old, he will benefit from orthotic treatment due to his unique developmental and medical history including Neurosurgery. He still has growth and mobility available in his cranium which is an important factor to consider when deciding on orthotic treatment. He can still achieve corrected cranial alignment.†10 Aetna is a company that has proven itself to be a leader in proactive management of health and well being. Members have learning resources, online tools and a vast library of information available to them to make wise decisions about their health. Aetna’s mission and values are consistent with that of a leader in the industry, and it is no surprise Aetna was named FORTUNE Magazine’s most admired company in the Health Care: Insurance and Managed Care category for the second year in a row. It is also no surprise that Aetna was ranked first among national health plans in the 2008 PayerView Rankings, as a company that pays physicians faster and denies claims less often than other health plans measured. For all of these reasons, we respectfully request that you reexamine the long-term benefits of the cranial remolding device for Burton despite his advanced age. The documented risks associated with untreated plagiocephaly, coupled with ’ neurological history, support the STARband helmet as a proven successful, non-invasive treatment program. Thank you for your consideration of our appeal. Respectfully, 1 Lima, Dulcy, CO, OTR/L. Orthotic Management of Pediatric Cranial Deformities Using STAR Cranial Remolding Orthoses 2 Hummell, P, Fortado D. Impacting Infant Head Shapes. Advances in Neonatal Care. 2005, 5:6:320-340. 3 Hutchinson, Lynne, Hutchinson Luke, , , , Ed. Plagiocephaly and Brachycephaly in the First Two Years of Life: A Prospective Cohort Study. Pediatrics Vol 114 No 4, October 2004, 970-980. 4 Littlefield TR, Pomatto JK, KM. Dynamic Orthotic Cranioplasty: Treatment of the Older Infant. Neurosurgical Focus 2000; 53:367-377. 5 RI., Clarren M.D. Long-Term Developmental Outcomes in Patients with Deformational Pagiocephaly. Pediatrics 2000, 5 (2/e26): 1-5. 6 Aregenta, L, , LR, Goldstein D, & Kilgo P. Long Term Developmental Outcomes in Children With Deformational Plagiocephaly. Craniofacial Surgery VI 2001: 65-67. 7 Balan P, Kushnerenko E, Sahlin P, Huotilainen M, Naatanen R, Hukki, J. Auditory ERP’s Reveal Brain Dysfunction in Infants with Plagiocephaly. 8 Dr. Mely Tan, Pediatrician – letter 9 Dr. Bakhtiar Yamini, MD, Assistant Professor Pediatric Neurosurgery – letter 10 Deanne Hilvert, PT – letter Quote Link to comment Share on other sites More sharing options...
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