Deep Brain Stimulation denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1This patient is an 11-year-old female who has progressive dystonia secondary to DYT-1 genetic defect. She has pursued standard non-surgical treatment including Botox, Artane, Baclofen, and Klonopin with limited benefit. The patient’s providers have recommended deep brain stimulation evaluation and treatment. The Health Plan has denied authorization for deep brain stimulation therapy on the basis that it is considered experimental.Upon review of the submitted clinical information and the medical literature regarding deep brain stimulation therapy there is sufficient evidence to support the conclusion that deep brain stimulation therapy is likely to be more beneficial for this patient than standard therapy. The submitted literature demonstrates that deep brain stimulation has benefited some patients with progressive dystonia unresponsive to standard therapy.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a deep brain stimulation device. Deep brain stimulation therapy is indicated for this patient’s obsessive-compulsive disorder (OCD). Deep brain stimulation has been shown in the medical literature to be very effective for OCD. Deep brain stimulation also gained U.S. Food and Drug Administration (FDA) approval for the treatment of chronic, severe, treatment-resistant OCD in adult patients who have failed at least three selective serotonin reuptake inhibitors (SSRIs). This patient meets the above criteria, and the patient is being recommended deep brain stimulation by the patient’s providers, psychologist, psychiatrist, and neurosurgeon. The patient has a nearly 40-year history of severe, treatment-resistant OCD.

Where the denial was upheld

Physician 1: This case concerns a 13-year-old male with Tourette’s syndrome and obsessive-compulsive behavior. The patient has been tried on various medications without significant benefit. He underwent deep brain stimulation in July 2006. The Health Plan has denied coverage for the procedure on the basis that it is considered investigational for treatment of Tourette’s syndrome.Tourette’s syndrome is a most difficult neuropsychiatric syndrome. It can be treated with a variety of combinations of medications with moderate success, as suggested and recommended recently by the Tourette’s Syndrome Association in New York. Presently, as cited in the submitted literature, deep brain stimulation is definitely experimental/investigational and may lead to serious unwanted and potentially fatal results.

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for motor cortex stimulation, deep brain stimulator, or spinal peripheral stimulator. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s trigeminal neuralgia. Findings: The physician reviewer found that Review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of peer-reviewed studies that show the use of peripheral nerve stimulation results in long-term benefit. A study performed a retrospective review of the medical records on patients who were trialed and implanted with occipital nerve stimulator (ONS) systems at one institution.

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 Deep Brain Stimulation, then check the rights and deadlines that apply to your plan.