Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional 10 units (for a total of 30 units) of neuropsychological testing services. In this case, the patient has medically and surgically refractory epilepsy, and is status post a partial resection of the right frontal lobe, with subsequent implantation of RNS. He continues to have numerous seizures daily, despite the stimulator and multiple anticonvulsant medications. There is concern that he may have reading reflexive epilepsy. He has an SCN1A mutation of uncertain significance. Meisler and colleagues note that mutations of SCN1A genes are responsible for a significant burden of neurological disease. SCN1A mutations have been associated with cognitive decline. In this case, the patient is struggling with reading comprehension, with difficulty in reading, writing and word-based math problems. The International League Against Epilepsy (ILAE) recommendations for neuropsychological testing for adults and children undergoing epilepsy surgery states that since cognitive decline is one of the most significant sequelae of epilepsy surgery, a postoperative neuropsychological assessment is essential in assessing outcome in this population and should be a mandatory component of epilepsy surgery. The recommendations further state that the same principles that inform the comprehensive nature of the preoperative neuropsychological assessment should guide the assessment of postoperative outcome and evaluate all aspects of cognitive and behavioral function, as assessed prior to surgery. In addition to all of the factors that influence an individual's neuropsychological profile in a presurgical assessment, the nature, timing and extent of the surgery, and other facets of postoperative outcome, particularly seizure control, must be considered in the interpretation of the results from a postoperative neuropsychological assessment. The recommendations further stress that the preoperative and postoperative neuropsychological evaluation in children is more complex, complicated by the fact that the epilepsy and the surgical resection influence the developing rather than the mature brain and hence developing cognitive and behavioral systems. Kaur and colleagues performed a retrospective cohort study including 186 children who underwent surgical resection for treatment of pharmacoresistant epilepsy and who completed preoperative and postoperative neuropsychological assessments. Postoperative testing occurred approximately six and a half months after surgery and included measures of intelligence, attention/working memory, processing speed, language, executive functioning, visuospatial skills, memory, and academic achievement. The authors concluded, `While 18% of children demonstrated no postoperative declines or improvements in any cognitive domain, the majority demonstrated relatively focal changes (declines and/or improvements in one to two cognitive domains). Rates of postoperative decline and improvement across individual cognitive domains were variable and ranged from 4% to 35% and 2% to 31%, respectively. Given that current medical literature supports detailed post-operative neuropsychological testing in pediatric epilepsy surgery, and may take a prolonged period for this patient with frequent focal seizures, the requested services are medically indicated. Therefore, an additional 10 units (for a total of 30 units) of neuropsychological testing services are medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with sub-specialty certification in neurodevelopmental disabilities and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.