Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Refractory obsessive-compulsive disorder
Treatment: CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay
The insurer denied: CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay
The denial is overturned.

This case involves an adult male diagnosed with treatment refractory obsessive-compulsive disorder (OCD). The patient has failed to sustain a response or remission with standard treatments. He has longstanding OCD (obsessive-compulsive disorder) since childhood with associated functional impairments and history of suicidal ideation in association with the psychiatric disorder. The obsessive-compulsive disorder is characterized by intrusive and obsessive thoughts and compulsive rituals that are time consuming. Again, the patient had exhausted and failed all reasonable standard treatments and underwent interstitial anterior capsulotomy last year with significant improvement. However, the patient experienced a recrudescence of symptoms with a re-evaluation and plan for a repeat neurosurgical procedure. The treatment plan for a repeat procedure with anterior capsulotomy/laser surgery was rigorously reviewed and approved per protocol. 
The health plan has denied coverage of the repeat neurosurgical procedure, CPT revenue code 61735, based on a coverage exclusion indicating that the procedure is considered experimental and investigational. 
The patient's physician has requested a reversal of the denial of coverage on the basis of the clinical history and the standard of care with regard to the requested procedure. The appeal indicates that the requested procedure is life-saving due to suicide risk and essential with regard to the recrudescence of symptoms of OCD (obsessive-compulsive disorder). The appeal indicates that the requested procedure is not experimental or investigational per the scientific literature and published guidelines for the treatment refractory OCD (obsessive-compulsive disorder). Moreover, the appeal asserts that the use of anterior capsulotomy can result in significant improvement as measured with standardized scales for obsessive-compulsive disorder (YBOCS), as in this case, and that the repeat procedure is medically appropriate. 

The health plan should cover the proposed treatment, CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay. 

The proposed treatment is reasonable and reflects sound medical judgment regarding the medical appropriateness and prevailing standards of medical practice. The use of CPT procedure 61735 in this case is in keeping with prevailing standards of medical practice and is considered medically appropriate with regard to the extensive scientific literature, referenced below.
The requested health service and proposed treatment with CPT Code 61735 is more beneficial than any standard treatment for the insured's condition or disease. 
The use of anterior capsulotomy can result in significant improvement as measured with standardized scales for obsessive-compulsive disorder (YBOCS-Yale-Brown Obsessive-Compulsive Scale), as in this case, and that the repeat procedure is medically appropriate, as all other standard treatments have been exhausted and failed. 
In this case, a repeat interstitial laser anterior capsulotomy with neurosurgical procedure CPT code 61735 is recommended in the context of treatment failure with multiple other treatments targeting symptoms of obsessive-compulsive disorder, which did not produce a sustained clinical response, or resulted in intolerance. Moreover, an initial treatment with the neurosurgical procedure resulted in significant improvement and scientific literature supports a repeat procedure, as planned and recommended.