Spect Scan denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 12-year-old female with a long history of severe anxiety, phobias and obsessive-compulsive symptoms. She has received treatment over the years with multiple combinations of medications and therapies. The patient had pervasive symptoms, which severely affected the patient’s normal social growth and development. A SPECT brain study was performed to clarify her diagnosis and offer treatment suggestions. The Health Plan has denied reimbursement for the SPECT scan at issue on the basis it was not medically necessary for evaluation of the patient’s medical condition.Review of the relevant medical literature reveals there is growing support for use of SPECT scans for diagnosis and management of psychiatric disorders. There is data demonstrating the efficacy of SPECT scanning in selected cases.

Where the denial was upheld

The patient is a 13-year-old male who was diagnosed with attention deficit disorder (ADD) approximately six years ago. He also has a history of vocal and motor tics as well as obsessive behavior. A SPECT scan performed on 3/18/04 demonstrated brain trauma with decreased left and right anterior pole and decreased posterior medial cerebellar profusion as well as parietal lobe dysfunction. The patient’s parent has requested reimbursement for the SPECT scan. The Health Plan has denied coverage stating the SPECT scan at issue is considered experimental.SPECT brain scans are not routine in the evaluation of attention deficit disorder. Even with the history of problems at birth and fetal distress, a SPECT scan is not used except on a research basis. The standard of care for ADD does not include SPECT scanning.

The patient is a 52-year-old female with reported Lyme Neuroborreliosis. She had an initial SPECT scan in 2002, which showed an “extensive hypoperfusion pattern predominantly in the frontal and temporal lobes and to a lesser degree in the parietal and occipital lobes.” A repeat SPECT scan in May 2004 showed “marked improvement of the hypoperfusion pattern in the temporal, frontal and parietal lobes since 7/18/02.” In the interim the patient received nine months of ceftriaxone therapy. No evidence has been provided regarding the serologic or cerebrospinal fluid status of the patient. No exam findings have been submitted as to her neurologic deficits and there is no information regarding her neurocognitive function. A request has been made for reimbursement for the repeat SPECT scan performed in May 2004.

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