Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #1:

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 a 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

The patient was previously diagnosed with orthostatic headaches, hearing loss, and tinnitus caused by cerebrospinal fluid leak. The patient underwent a successful transvenous embolization. The procedure resulted in resolution of symptomatic cervical spinal fluid leak and associated headaches, hearing loss, tinnitus, and disequilibrium. The patient received a notice of adverse determination stating that the surgery was not covered as it was considered experimental/investigational.  

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.

Literature notes that endovascular transvenous embolization is a novel treatment for patients with spontaneous intracranial hypotension (SIH) secondary to CSF-venous fistulas (CVF). The procedure is highly efficacious and safe treatment for CVF in patients with SIH. Based upon the provided information, it was determined that while there are other treatment options available to correct a sternal spinal fluid leak due to a fistula, evidence has shown that the vascular coil embolization is likely to be as beneficial or more beneficial than other standard treatment options for patients such as this. After a review of the provided information and a reference to current peer-reviewed articles, it was determined that denial of coverage for the surgical procedure was incorrect. Vascular coil embolization is no longer considered experimental/investigational as there is sufficient evidence to support that it is safe and effective for treatment of cerebral spinal fluid leaks. As such, the surgical procedure to prevent continuing cervical spinal fluid 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 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.