Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cerebrospinal fluid leak

Treatment: surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak

The insurer denied coverage for surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak

The denial is overturned

This patient was diagnosed with a cerebrospinal fluid leak resulting in debilitating orthostatic headaches, hearing loss, and tinnitus who underwent a procedure to close the vascular opening or fistula in the spinal vein. The procedure consisted of embolization, which successfully resolved the patient's condition. The patient received a notice of adverse determination stating that the vascular coil embolization was experimental/investigational for the treatment of cerebrospinal fluid venous fistulas given lack of evidence of improved outcomes.  

Scientific evidence and peer-reviewed literature supports a result of improvement in health outcome.

The surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak does not need final approval from the appropriate regulatory bodies for this diagnosis.

This patient was a good candidate for the surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak.

The surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested service is likely to be as beneficial or more beneficial than other standard treatment/procedures for this patient.

Current medical literature notes that spinal cerebrospinal fluid venous fistula (CVF) is a recognized cause of chronic positional headache and spontaneous intracranial hypotension (SIH). Literature notes that transvenous endovascular embolization can be used to treat this condition. Records noted the patient had documented evidence of a cerebrospinal fluid leak causing various symptoms. She successfully underwent transvenous embolization. Given her noted diagnosis and evidence within current peer-reviewed medical literature confirming that the embolization is a safe and effective procedure for this condition, the prior determination will be overturned given that this is not experimental or investigational. As such, the surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak was medically necessary.

In summary, the denial of the surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak and coverage for the requested service/treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.