Deep Brain Stimulator denials in California external review
In the California DMHC record, independent physician reviewers decided 15 published external-review cases involving Deep Brain Stimulatorand overturned the plan’s denial in 93.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Deep Brain Stimulator denials
| Category | Decisions | Overturned |
|---|---|---|
| Epilepsy | 4 | 75% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for implantable spine neurostimulator. In a systematic review of 14 prospective studies, researchers concluded, “Based on our analysis of the available evidence, there is moderate-quality evidence for the safety and efficacy of spinal cord stimulation for painful diabetic neuropathy.” In a retrospective study of 89 patients that assessed pain relief and functional improvements for patients with diabetic neuropathy who were permanently implanted with a high-frequency spinal cord stimulation device, researchers reported, “At the last assessment, 79.5% (58 out of 73) of patients were treatment responders, defined as having at least 50% patient-reported pain relief from baseline.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of motor cortex stimulator in the brainFindings: Three out of three physician reviewers found that the authorization and coverage for implantation of motor cortex stimulator in the brain is likely to be more beneficial for the enrollee than any available standard therapy.Neuropathic facial pain syndromes are known complications of dental procedures. Although this pain is generally unilateral and in the region of the face and mouth/jaw, it often involves continuous burning pain symptoms. It is well-established that the continuous feature of a chronic pain syndrome is a poor prognostic feature. In the context of an overall poor response to all treatments, conservative treatment with medications is recommended as the first approach.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for deep brain stimulation (DBS). The records provided for review document that this patient is status post two invasive surgical procedures in an attempt to make her a suitable candidate for resection of a seizure focus and she has failed to respond adequately to medical therapy. Based on the records reviewed, the patient is a candidate for two standard surgical interventions for her medically refractory epilepsy with either responsive neurostimulation or vagal nerve stimulation. However, there is a lack of data supporting a role for DBS for treatment of this patient’s medically refractory epilepsy.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Stimulator, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY