Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Tourette's syndrome. 
Treatment: Deep Brain Stimulation (brain stimulation of the subthalamic nucleus or globus pallidus). 
The insurer denied coverage for Deep Brain Stimulation (brain stimulation of the subthalamic nucleus or globus pallidus). 
The denial is upheld. 

This is a young adult female where the treating provider has diagnosed the patient with Tourette's Syndrome associated with self-injurious behavior (SIB). 

The treating provider is requesting therapy with deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus, which is under review. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes. 

Deep brain stimulation of the subthalamic nucleus or globus pallidus does not have final approval from the appropriate regulatory bodies for this diagnosis. DBS is not Food and Drug Administration (FDA)- approved for Tourette's. 

This patient is not a good candidate for deep brain stimulation of the subthalamic nucleus or globus pallidus. 

Deep brain stimulation of the subthalamic nucleus or globus pallidus is not the best available treatment for this patient at this time. The adverse risks are increased over standard treatment/services. There is no indication that the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

"Bilateral posteroventral globus pallidus (GPi) DBS could relieve the motor tics and depressive symptoms of the enrolled patients significantly, but the vocal tics and other psychiatric symptoms presented a progression without statistical difference during the follow-up period. The results of this study suggested that bilateral posteroventral GPi are effective targets for the motor tics in Tourette (GTS) patients, especially with prominent depressive symptoms."(Liu, A., et al 2022) 

"In recent years, deep brain stimulation (DBS) of basal ganglia-thalamocortical networks has emerged as a promising intervention for refractory GTS with or without psychiatric comorbidities. Three major challenges need to be addressed to move the field of DBS treatment for GTS forward: patient and DBS target selection, ethical concerns with treating pediatric patients, and DBS treatment optimization and improvement of individual patient outcomes (motor and phonic tics, as well as functioning and quality of life)."(Xu, W., et al 2020) 

"The selection of patients with Tourette syndrome (GTS) for deep brain stimulation (DBS) surgery rests on 5 fundamental pillars. However, the operationalization of the multidisciplinary screening process to evaluate these pillars remains highly diverse, especially across sites. High tic severity and tic-related impact on quality of life (first 2 pillars) require confirmation from objective, validated measures, but malignant features of GTS should per se suffice to fulfill this pillar. Failure of behavioral and pharmacologic therapies (third pillar) should be assessed taking into account refractoriness through objective and subjective measures supporting lack of efficacy of all interventions of proven efficacy, as well as true lack of tolerability, adherence, or access."(Martino, D., et al 2021) 

In summary, the denial of deep brain stimulation of the subthalamic nucleus or globus pallidus and coverage for the requested service/treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.