Intractable Epilepsy denials in California external review

What the reviewers wrote

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.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving intractable epilepsy, then check the rights and deadlines that apply to your plan.