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

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. Therefore, I have determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:  The patient is a 21-year-old woman with intractable partial seizures beginning at age 11.  The usual epilepsy therapy has failed and she has persistent secondary generalization. The patient is markedly disabled by her seizures. Studies thus far suggest a focal occipital lobe source that may be appropriate for epilepsy surgery. The comprehensive epilepsy clinic at an academic medical center has recommended magnetoencephalography (MEG) to potentially avoid extensive electrocorticography. The patients provider has requested authorization for MEG to further investigate the focus of her seizures. The Health Plan denied authorization citing the investigational nature of the diagnostic procedure in this clinical context.The patient in this case has intractable seizures and is a likely candidate for epilepsy surgery. Epilepsy specialists and surgeons have been using MEG for several years and case series as well as expert opinion strongly support its usefulness in the evaluation of potential epilepsy surgery patients. Furthermore, MEG has been recommended by a specialized team who has experience with the procedure and knows its value in optimizing surgical outcomes. Therefore, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 21-year-old female with longstanding pharmaco-refractory epilepsy who is being evaluated for possible resective epilepsy surgery. Her seizures have been disabling and have not responded adequately to medications including Tegretal/ Carbatrol, Depakote, Topamax, Dilantin, Keppra, Trileptal and Depo-Provera. Diagnostic studies to date have given conflicting localization information. MRI revealed mild hyperintensity and mildly decreased volume of the left hippocampus but PET scan revealed a right occipital hypometabolic focus when co-registered with MRI. The CNP conference consensus was that the patients evaluation supported an occipital epileptogenic region. Magnetoencephalography (MEG) was recommended to maximize the localization of seizure focus prior to invasive monitoring. The Health Plan has classified this approach as experimental/investigational and denied the patients request for authorization.MEG is a technology that allows 3-dimensional localization of epileptic spike focus. It is now the imaging modality of choice where a precise and high degree of localization is required. MEG can also be used to localize the primary sensory cortices (visual, auditory, or somatosensory) and areas involved with receptive language function. Studies show MEG is superior to standard direct and indirect measures. The sensitivity of EEG is limited, and this modality records only from superficial areas of the cortex; a deeper irritative focus would not be identified. Precise knowledge of seizure focus is essential for resective epilepsy surgery. Invasive monitoring is frequently required, but may be minimized if a deep focus has been identified in advance. MEG allows identification of deep irritative foci and is an accepted tool in the preoperative evaluation of epilepsy surgery patients. Based upon the information set forth above, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.