Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Intractable epilepsy. 
Treatment: laser interstitial thermal therapy (LITT). 
The insurer denied coverage for laser interstitial thermal therapy. 
The denial is overturned. 

Patient is a female child with a history of tuberous sclerosis (TS) and intractable epilepsy. The patient presented to the Pediatric Neurosurgeon's office for a postoperative visit after stereo-electroencephalography (SEEG). The patient had 12-15 seizures per day. The patient has tried and failed phenobarbital, klonopin, Keppra, Vimpat, phenytoin, Onfi, oxcarbazepine, Depakote and Fycompa. She has tried ketogenic diet. She is currently on Onfi and epidiolex. She takes Diastat as her rescue medication. The patient has had multiple open craniotomies. The physician recommended laser interstitial thermal therapy (LITT) to treat the patient's condition.

Computed tomography (CT) of the brain/head without contrast states, "Compared to a prior study, there are now areas of cystic encephalomalacia within the right occipital and parietal lobes with ex vacuo dilatation of the right lateral ventricle. No gross shift, hemorrhage or hydrocephalus".

Magnetic resonance imaging (MRI) of the brain states, 
"1. Moderate size region of encephalomalacia and gliosis within the right parietal, temporal, and occipital lobes as detailed above with ex vacua dilatation of the posterior lateral ventricle. Findings are without significant change since prior exam.
2. 3 millimeter (mm) enhancing focus within the right caudothalamic groove, without significant change in size from prior examinations. Findings may represent a subependymal nodule. Continued imaging surveillance Is suggested as clinically appropriate, to exclude enlargement of a subependymal giant cell astrocytoma.
3. No significant change in size of a discrete focus of 12 hyperintensity within the left anterior thalamus which may represent sequoia of chronic ischemic change.
4. Again demonstrated linear-like foci of T2/FLAIR hyperintensities (reflects the difference in the brain tissue at one part of the brain compared to the rest)  within the bilateral supratentorial compartment, likely corresponding to areas of prior stereotactic electroencephalogram (EEG) lead placement.
5. Suggestion of decreased caliber of the right optic tract compared to the left, suboptimally evaluated on current examination. Correlation with formal ophthalmologic evaluation is suggested as clinically appropriate."

This patient has a history of tuberous sclerosis and intractable epilepsy. The patient has 12-15 seizures per day. The patient has tried and failed phenobarbital, klonopin, Keppra, Vimpat, phenytoin, Onfi, oxcarbazepine, Depakote and Fycompa. She has tried ketogenic diet. She is currently on Onfi and epidiolex. She takes Diastat as her rescue medication. The patient has had multiple open craniotomies. Given the multiple failed therapies and continued epilepsy the request for inpatient procedure for laser interstitial thermal therapy (LITT), is considered more beneficial for this patient's diagnosis than alternative treatments.

The scientific evidence in peer-reviewed literature supports improvement in health outcome for this patient's clinical scenario.  Inpatient procedure for laser interstitial thermal therapy (LITT), has approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for laser interstitial thermal therapy (LITT).  Laser interstitial thermal therapy (LITT) is the best available treatment for this patient at this time.     

The adverse risks are lower than standard treatment as this modality is less invasive than open resection.     

In summary, the denial of inpatient procedure for laser interstitial thermal therapy (LITT), should be overturned.