Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 15-year-old male who experienced a sudden onset of encephalopathy of undetermined cause, which left him with a neuropsychological deficit from which he has recovered slowly and incompletely. The patient has been followed by a neuropsychologist. His parents are requesting reimbursement for cognitive rehabilitation therapy the patient received from April 2004 to August 2004. The Health Plan has denied this request indicating the therapy at issue is considered experimental for treatment of the patients medical condition.Review of the clinical evidence reveals the cause of the patients acute encephalopathy was undetermined, and the patient had residual deficits requiring treatment.  Cognitive rehabilitation therapy is a medically reasonable and appropriate therapy for treatment of patients such as this patient. In this clinical setting, the use of standard therapies was not likely to be beneficial. Accordingly, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 15-year-old male who became acutely confused and disoriented at school in May 2003. He did not eat or drink much for four days. After this episode he experienced a great deal of anxiety and his academic performance deteriorated badly. In April 2004 he underwent extensive neuropsychological testing, which showed several areas of difficulty and dysfunction. The psychologist who performed this evaluation recommended cognitive rehabilitation and began treating the patient for acute stress disorder. The patient also was treated with Risperdal in low doses. Based upon the information provided, it appears the patient continues to have symptoms including poor school performance 13 months after the initial incident. The Health Plan has denied reimbursement for cognitive rehabilitation therapy on the basis it is considered experimental.Review of the records provided does not demonstrate cognitive rehabilitation was beneficial for this patient. Furthermore, it does not appear the diagnosis of acute stress disorder alone could account for all the patients problems. The patients neuropsychological testing revealed a number of areas of dysfunction. As the patients psychologist indicated, there was evidence of significant areas of brain impairment that were suggestive of biological or biochemical factors beyond a simple stress disorder. Thus, it appears psychiatric treatment and psychopharmacologic treatment were likely to be of greater benefit than cognitive therapy in this case. Accordingly, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 15-year-old male, previously in good psychological health, who became confused and disoriented at school in May 2003, unable to remember people or where to go next. It was noted the patient was not making sense, was unable to make simple decisions, and got on and off the bus three times. He next went to study hall, but was sitting in the wrong room, found later by the principal wandering down the hall. He was unable to remember people previously known to him, and did not eat or drink much for the next four days. He was also noted to have lost his sense of humor, became much more isolative from friends, and grew uncomfortable in being outside. By August 2003, the patient started interacting with friends again though felt as though he had forgotten how to read or perform simple math. Laboratory tests and MRI results were negative. The patient was thereafter diagnosed with acute stress disorder. He was also prescribed low dose Risperdal and rejoined school, but on a half-time basis, noting a great deal of difficulty in learning and remembering. Some testing by the school psychologist showed the patient to have impairments in sequences and recall of visual and auditory information. The patients parents also noted him to have improved some since August 2003 though not to premorbid levels. His parents indicate it was difficult for him to concentrate or remember, with continued decrease in energy level and a new tendency to nap daily despite the lightened school load. Additionally, he was noted as more irritable, though not depressed per se. The patient was no longer involved in any of the social activities in which he was once active.In April 2004, the patient underwent an extensive neuropsychological battery and was found to have severe deficits in finger agnosia, graphesthesia, sustained attention, and concentration. He also demonstrated spelling dyspraxia, dyscalculia, left/right confusion, and significant constructional dyspraxia. In addition, the patient was noted to have impaired logic and abstract reasoning. Subsequently, he entered into cognitive rehabilitation therapy; review of the notes provided shows the main focus of the therapy was on sequencing, construction, and recall. The notes demonstrate the patient made some progress in these domains.At issue in this case is whether cognitive rehabilitation therapy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.The patients history lacks any of the elements of an acute stress disorder. Given all the activities in which the patient was once happily involved it is not clear what would have precipitated this sort of presentation Additionally, the patients presentation at the time of worst affliction as well as his subsequent evaluation and course are hardly in keeping with the diagnosis of acute stress disorder. Anxiety and depressive symptoms were not especially notable in his presentation. Rather, the patients cognitive deficits were paramount, as documented in extensive neuropsychological testing. In fact, many of his deficits are nearly classic for Gerstmanns syndrome, typically representative of a lesion of the dominant parietal lobe. The underlying etiology for his confusional state is yet to be determined, though an unremarkable MRI scan does not rule out a primary, neurological process as instrumental in his decline. Based upon the results of the patients neuropsychological testing and the absence of evidence of acute stress disorder, the patient was an appropriate candidate for cognitive rehabilitation therapy. Given the extent of the patients cognitive deficits, the therapy at issue was medically reasonable and appropriate to attempt to further cognitive development. Based upon the information set forth above, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.