Magnetoencephalography denials: what the review data shows

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

The parents of an 18-year-old female enrollee have requested magnetoencephalography (MEG) and magnetic source imaging (MSI) for an evaluation of the enrollee’s focal epilepsy. Findings: Two physician reviewers found that these tests remain investigational for evaluation of the patient’s condition. The patient has undergone a number of standard diagnostic procedures, which indicate that the seizure focus stems from the left frontal lobe. A large number of standard anti-epileptic drugs have not been effective and have produced intolerable and unwanted side effects. The patient is now a candidate for surgical resection of the lesion that is responsible for the seizures. A reliable and accepted technique for successful surgical ablation of the epileptic focus is the use of intraoperative corticography. The requested tests show promise as eventually becoming standard tests.

A 20-year-old male enrollee requested authorization and coverage of a magnetoencephalography (MEG) study. The Health Plan denied the request indicating that the requested MEG study is not medically necessary for evaluation of the enrollee’s seizure disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plan’s denial on the basis that the requested MEG study is not medically necessary.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Magnetoencephalographywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.