November 8, 2011
Appeals Personnel
Name and Address of Insurance Company
RE: Appeal of Coverage for a Comprehensive Gait Analysis Testing
Referring Physician: _______________, M.D.
Patient Name:
_______________
Insured’s Name:
_______________
DOB:
_______________
Diagnosis:
ICD code and Description
I.D. Number:
_______________
Facility:
Name of Hospital
Requested Procedures: 97001 Physical Therapy Evaluation
96001 Comprehensive Computerized Motion
Analysis Testing
96002 Dynamic Surface Electromyography
96003 Dynamic Fine Wire Electromyography
96004 Physician Review and Interpretation of
Motion Analysis Testing Data
Dear appeals Personnel,
I’m writing to appeal the denial of coverage of a Comprehensive Gait
Analysis Test for ______________. _____ is an __ year old male/female
with cerebral palsy. She/he has some ongoing gait deviations which are
interfering with her/his function. The complex nature of her/his neuromuscular and boney involvement makes it impossible to accurately
determine what boney and/or soft tissue problems need to be addressed to
improve her/his walking ability without a gait analysis test. The gait
analysis study is medically necessary to objectively evaluate _____’s
complex walking problems and determine the appropriate interventions to
improve her walking ability. The gait analysis test will prevent unnecessary
surgeries from being performed.
The specific reason stated for not covering the comprehensive gait analysis test is that
_______________________________________________________(sample: “…the evidence is
too limited to draw definitive conclusions regarding the role of gait analysis in the
continuum of care”.) This medical policy is outdated and omits the evidence found in the
current literature. There are many recent peer-reviewed studies in the literature that document
the use of comprehensive gait analysis testing in patients with cerebral palsy improves the
outcome of orthopaedic care as well as decreases the cost of care. I urge you to review the more
recent literature cited in this letter so that the decision on the needed services is based on the
current literature. At the end of this letter you will find an extensive list of research articles
published in peer reviewed journals documenting motion analysis testing as the standard of care
for individuals with walking problems due to cerebral palsy. Two recent studies not addressed
in the denial letter demonstrate the dramatic decrease in costs and the decrease in the need
for future surgeries if comprehensive motion analysis testing is done prior to the initial
surgery. In 2008 Ounpuu, et al published the results of a study demonstrating the average
charges for a single event multilevel surgical approach carried out based on the results of a
gait analysis test were close to half of the charges for the same surgeries carried out in a
staged approach addressing one problem at a time. In 2009 Wren, et al published the results
of a study demonstrating three times more surgeries per person year for ambulatory
patients with cerebral palsy who DID NOT have gait analysis testing prior to their initial
surgery. In 2011 Wren, et al published a systematic review of the current evidence base
related to the efficacy of gait analysis which I strongly urge you to review. Wren, et al also
recently completed a 5 year randomized controlled study on the impact of gait analysis on
the outcome of care. The findings were presented at NIH in April 2011 and showed that the
use of clinical gait analysis prior to orthopaedic surgery in children with cerebral palsy
improved their walking ability and their overall health.
The alternative to making surgical decisions for _____ based on the gait analysis data is to make
surgical decisions based on clinical assessment and visual assessment alone. It is well
documented in the literature, that this consistently leads to repeated encounters with surgeries and
often recurrence of deformities necessitating repeat surgery (Fabry, Liu, & Molenaers, 1999; J.
Gage, 1994). The recent literature also clearly documents better surgical outcomes when gait
analysis data is used to determine the surgical plan (Filho, Yoshida, Carvalho, Stein & Novo,
2008).
There are also many peer reviewed publications that include long-term patient outcome data that
demonstrates its efficacy beyond informal visual analysis of gait abnormalities routinely
performed by clinicians. Studies demonstrate long-term patient outcome data at both 5 and 10
years is clearly far superior to the old results (S Õunpuu, DeLuca, Davis, & Romness, 2002;
Sylvia Õunpuu, Keggi, Davis, Bell, & DeLuca, 1996). In fact, the need for repeat surgery has
been found to be less than 10% in patients followed out over 10 years. Although one could
conclude that the delivery of multilevel surgery alone is the cause of these favorable outcomes,
this would be incorrect. The ability to evaluate a patient with complex walking problems at
multiple levels including pelvis, hip, knee, ankle and foot is made possible only with threedimensional gait assessments. The ability to package surgeries at multiple levels at a single
sitting necessitates an appropriate pre operative assessment so that the correct surgical plan can be
delivered.
The benefits of gait analysis are further emphasized by making comparisons with the “old”
literature based on single level surgery in cerebral palsy, which is fraught with over correction,
under correction or the need for repeat surgery (Fabry et al., 1999). The overall results of the
single staged surgery approach have led to “excessive morbidity and permanent weakness”(J. R.
Gage, 2004). As a referral center for complex gait problems we very frequently see unfortunate
results of surgeries performed at centers without gait analysis and without an understanding of
basic gait principles. As we have had the ability over the past 20 years to evaluate long-term
outcomes, we know that our outcomes using gait analysis are far superior.
It has also been well established that the informal visual analysis of gait abnormalities, which
unfortunately is the standard of care in many locations, is not acceptable. It has been well
documented that there is considerable variation in observer agreement for the most common
clinical assessment measures (Keenan et al., 2004; Saleh & Murdoch, 1985). As well,
evaluations based on clinical assessment of joint range of motion, measure of spasticity, strength,
x-rays and visual observation frequently do not correlate with the dynamic findings during a gait
analysis (P. DeLuca, Õunpuu, Davis, & Walsh, 1998; McMulkin, Gulliford, Williamson, &
Ferguson, 2000; Orendurff, Chung, & Pierce, 1998). This is particularly an issue in those with
neuromuscular gait disorders where the impact of abnormal muscle tone increases significantly
during functional activities such as gait in comparison to the reclined or sitting positions of the
clinical examination. As stated by Lee (E. H. Lee et al., 1992), the “combination of a careful
clinical assessment and gait analysis can produce the better results in surgery for children with
cerebral palsy”.
Several recent studies have demonstrated improved outcomes for individuals with complex
walking problems when surgical recommendations, based on findings from threedimensional gait analysis, were followed (F. Chang, 2006; M. Filho, 2008; T. Wren, 2008).
Chang, et al evaluated fourteen children with cerebral palsy who had undergone two
comprehensive gait analyses spaced at least one year apart. Subjects in the control group were
assigned surgical recommendations based on findings from the first gait study, but did not
undergo any surgery. The experimental group of children received surgical recommendations
based on gait analysis, and then underwent the prescribed surgical procedures. Prior to the
surgical procedures for the experimental group, the two groups were matched for identical
surgical recommendations based on their initial gait analysis evaluations. The second set of gait
analyses were performed one year post-operatively for the experimental group, and one year
following the first gait evaluation for the control (no-surgery) group. Findings demonstrated that
the control group (those who did not have the prescribed surgical procedures) had only 19.9%
positive outcomes, and the experimental group (those who underwent the prescribed surgical
procedures) had 46.7% positive outcomes based on post-surgical evaluation criteria. This study
illustrates that individuals with complex walking problems have superior outcomes when they
undergo the surgical procedures recommended after three-dimensional gait analysis.
A more recent study (Filho, et al 2008) demonstrated that the use of three-dimensional gait analysis
prior to surgery leads to improved clinical outcomes in children with cerebral palsy. In this study
38 patients with cerebral palsy were divided into four groups according to the agreement between
the recommendations from gait analysis and the procedures actually carried out. Fifteen additional
patients with cerebral palsy whose surgical intervention was postponed were utilized as the control
group. No gait improvement was noted in the control group or in patients whom no procedures
recommended by the gait exam were performed. Improvements in walking were observed after
treatment in the other three groups with more significant improvements being directly correlated
to increased agreement between the motion lab recommendations and the actual treatment carried
out.
An important positive outcome associated with the use of gait analysis is a reduction in the
need for future surgery when comparing patients who underwent three-dimensional gait
analysis prior to surgery to those who did not (T. Wren, et al, 2008). This study retrospectively
evaluated 756 ambulatory patients with cerebral palsy who underwent lower extremity surgery to
improve their walking ability. The need for future surgery was compared between the 578 who had
three-dimensional gait analysis testing prior to their initial surgery and the 178 patients who did not
have gait analysis testing prior to their initial surgery. After adjusting for GMFCS level, the mean
number of additional surgeries per person-year was significantly lower in those who had gait
analysis testing prior to their initial surgery.
The ability to deliver multilevel surgery and better outcomes is certainly not only a benefit to the
patient and their family, but also a benefit to the cost of health care delivery in general. Clearly
providing a single hospitalization and recovery period and rehabilitation period is more efficient
and cost favorable than the system of 25 years ago.
Based on a review of the current literature I am requesting the approval of the Motion Analysis
Test for __________. As you can see, the Motion Analysis Test is a critical to determining the
most appropriate treatment and surgeries to improve ______’s walking ability and function in the
community.
Sincerely,
________________, M.D.
Name and Address of Referring Physician
References: Motion Analysis Testing
Articles in bold are recent articles documenting the efficacy of gait analysis testing.
Bleck, U. E. (1987). Orthopaedic Management in Cerebral Palsy. Philadelphia: Mac Keith Press.
Carollo J.J., Matthews D. (2002). Strategies for clinical motion analysis based on
functional decomposition of the gait cycle. Phys Med Rehab Clin N Am, 13:949-977.
Chang F., Meininger A.K., Carollo J.J. (2006). Comparison of outcomes in children with cerebral
palsy when the recommendations from gait analysis are observed. J Pediatr Ortho, 26(5): 612616.
Cook, R. E., Schneider, I., Hazlewood, M. E., Hillman, S. J., & Robb, J. E. (2003). Gait analysis
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Davids, J. R., Õunpuu, S., DeLuca, P. A., & Davis, R. B. (2004). Optimization of walking ability
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