Neurofeedback denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested neurofeedback treatments once or twice weekly, monthly or bi-monthly cognitive rehabilitation sessions with a clinical psychologist and twice a week meetings with a cognitive rehabilitation coach to practice the cognitive exercises prescribed by the clinical psychologist during the cognitive rehabilitation sessions for treatment of her medical condition. Findings: The physician reviewer found that there is a lack of sufficient support in the peer-reviewed literature for neurofeedback treatments in this clinical setting. The study by Choobforoushzadeh and colleagues assessed the use of neurofeedback in 24 patients with MS. Although the results at two-month follow-up were positive, larger studies with long-term follow-up are needed to confirm these findings.

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested reimbursement and prospective authorization and coverage for neurofeedback therapy. This patient presents with a history of attention-deficit/hyperactivity disorder (ADHD), generalized anxiety disorder (GAD), and sensory processing disorder. The provider reports that some of the patient demonstrates some autistic features and symptoms of depression. His provider has recommended neurofeedback after the patient failed to improve with maximally dosed amantadine and occupational therapy. Neurofeedback is a specific form of biofeedback that involves electroencephalography (EEG) to improve brainwave activity, particularly in patients with anxiety disorder.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Neurofeedback (biofeedback) therapy.American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for obsessive-compulsive disorder (OCD) state that when possible, cognitive-behavioral therapy (CBT) is the first line treatment for mild to moderate cases of OCD in children. The practice parameters state that for moderate to severe OCD, medication is indicated in addition to CBT.

The patient is a 17-year-old male diagnosed with ADHD. He was treated with Concerta, Adderall and Wellbutrin and appeared to respond well to the medications. The patient’s mother noted that he became “less tolerant” of his medications after a time and she concluded that he had become depressed. The patient’s parents believed that his “depression” was caused by the medications and that the medications were “harmful” to him. The parents elected to discontinue the medications and seek alternative evaluation and treatment of the patient’s ADHD. The patient underwent a neurobehavioral evaluation that included an EEG and neuromuscular testing followed by neurofeedback treatments. The Health Plan denied coverage and the family now requests reimbursement for the procedures. It appears that the initial diagnosis of ADHD was accurate and the choice of medications appropriate.

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 Neurofeedback, then check the rights and deadlines that apply to your plan.