Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioblastoma  
Treatment: Neurosurgery/Spine Services  

The insurer denied Neurosurgery/Spine Services (Laser Interstitial Thermal Therapy for Tumor, code 64999).  The denial was reversed.   

This is a male patient who was status post right temporo-occipital mass resection with findings of a glioblastoma with a WHO grade IV.  He underwent a magnetic resonance imaging (MRI) that revealed disease progression in the surgical margins with multifocal distribution of new disease in both sides of the splenium of corpus callosum, right inferior occipital lobe and along the right occipital horn; massive enlarging of the glioblastoma 4.5 cm in diameter.  He had complaints of worsening headaches.  Concerns were raised regarding the patient's ability to tolerate radiation and chemotherapy; his provider offered he undergo an aspiration of the cystic component of the tumor followed by laser ablation.  Due to the progression in the colossal lesion growth Laser Interstitials Thermal Therapy (LITT) was suggested rather than radiotherapy due to the lesion growth.  The patient underwent a craniotomy, burr hole insertion, and LITT procedure.  

Based on the review of the medical record, the LITT procedure was medically necessary in this case.  The tumor was deep-seated and inoperable by standard treatment.  If left untreated, the tumor would have been likely to result in devastating consequences.  Because of the massive tumor growth that reached 4.5 cm in diameter, there was a clinical concern that this tumor would impair the patient's ability to tolerate radiation and chemotherapy.  According to literature review, there are multiple studies that show that the LITT procedure is a safe, effective treatment.  

Literature shows that since the first implementation of laser therapy for intracranial tissue ablation, treatment of a variety of intracranial lesions was attempted, including metastases, radiation necrosis, meningiomas, ependymomas, as well as gliomas.  Despite maximal therapy, survival remains poor for these tumors, and the survival rate without any treatment is 9 weeks.  With maximal treatment, according to the latest guidelines, the survival can be prolonged to 14.6 months.  Studies have shown that the combined use of radiation and temozolomide protocols increase survival rates to 27% at 2 years.  

Recently, a meta-analysis of the efficacy of LITT treatment of newly diagnosed and recurrent high-grade gliomas was published.  Ivan et al. extracted information and analyzed the data pertaining to treatment and outcomes of newly diagnosed high-grade gliomas treated with laser interstitial thermal therapy (LITT).  This study identified four articles that reported this treatment on 25 patients with newly identified gliomas.  Tumor volume was available for 22 patients, and the mean was 16.5 cm, whereas the extent of volume treated with laser was available for 9 patients with an average of 82.9% tumor coverage.  Complications data was available for 13 patients, and there were no intraoperative mortality or complications.  Outcome analysis revealed a mean follow up of 7.6 months, with 12 patients still followed or lost to follow-up.  Median overall survival was 14.2 months and the average progression-free survival was 5.1 months.  These results are similar to results reported in the literature that vary from 8.5 to 14.5 months.  Thus, this systematic review demonstrates that LITT is a safe and effective procedure for newly diagnosed high-grade gliomas achieving outcomes similar to cases with open surgical resection.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.  

Based on this review of the patient's medical record and literature pertaining to the recommended procedure, the medical necessity for the neurosurgery/spine services (laser interstitial thermal therapy for tumor, code 64999) provided is substantiated.  The insurer's denial is reversed.