Intractable Epilepsy: when insurers say no, reviewers often say yes
In 16 published external-review decisions involving intractable epilepsy, independent physician reviewers overturned the insurer’s denial 93.8% of the time.
Most-fought treatments for intractable epilepsy
| Category | Decisions | Overturned |
|---|---|---|
| Magnetoencephalography | 3 | 100% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 11 | 100% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 5 | 80% |
Where the denial was overturned
Physician 1: The patient is a 21-year-old female who was diagnosed with epilepsy ten years ago. She has frequent seizure activity of various types and medications have not brought her seizures under control. The patient is requesting authorization for MEG as part of a workup for possible epilepsy surgery. The Health Plan considers the diagnostic proceed investigational and has denied the requested authorization.Magnetoencephalograpy (MEG) remains an experimental and investigational technique. At this time, the ability of MEG to identify foci of seizure activity remains unproven. There is no substantial proof of its effectiveness for the treatment of intractable epilepsy. Thus, MEG is not likely to be more efficacious than standard imaging techniques.
Physician 1: The patient is a 47-year-old female who has experienced intractable seizures since childhood. A large number of anti-seizure medications have been tried without significant improvement. The patient is contemplating neurosurgery to ablate the seizure focus. Prior to surgery, it has been recommended that she undergo magnetoencephalography (MEG). The Health Plan has denied authorization for the requested diagnostic procedure on the basis that it remains investigational at this time.Review of the medical literature reveals that the clinical usefulness of MEG in this setting has not yet been established. MEG is a relatively new diagnostic procedure and has not been fully refined. To date, the success rate has not been impressive. As such, it is not likely that MEG will have clinical value in the evaluation of this patient’s long-standing seizure problem.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the use of a power standing feature for the already approved powered wheelchair. The records indicate that this patient presents with complex intractable epilepsy, developmental delay, cellulitis, neuropathy, mild ataxia, and paraplegia with hypotonia. The patient has been noted to currently require a manual wheelchair for mobility that a caregiver must propel. The medical records lack sufficient documentation regarding the patient’s current level of function in terms of performing daily activities and mobility, as well as physical examination findings, including graded motor strength and range of motion of the upper and lower extremities.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for intractable epilepsy was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY