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. 

The patient has a diagnosis of tuberous sclerosis and medically refractory epilepsy. The patient has tried and failed phenobarbital, klonopin, Keppra, Vimpat, phenytoin, Onfi, oxcarbazepine, Depakote and Fycompa. The patient underwent stereo-electroencephalography (SEEG) and the ictal onset zone was identified. The patient is now recommended LITT for treatment of the ictal onset zone. 

The use of laser ablation for mesial temporal sclerosis is well accepted within the epilepsy surgery community. There has been extensive experience and several large studies that show this is an appropriate option for many. 

The following studies confirm this: 

"LiTT appears to be a safe and effective surgical option for treatment resistant [mesial temporal lobe epilepsy] MTLE, particularly among patients with mesial temporal sclerosis MTS. Remission of presurgical mood and anxiety disorders can also result from LiTT." (Kanner AM, et al.,2022). 

"These findings suggest that while verbal memory function can decline after laser ablation of the amygdalohippocampal complex, it is better preserved when compared to open temporal lobe resection. Our findings also highlight that the dominant hippocampus is not uniquely responsible for verbal memory. While this is at odds with our simple and common heuristic of the hippocampus in memory, it supports the findings of non-human primate studies showing that memory depends on broader medial and lateral [temporal lobe] TL regions." (Drane DL, et al., 2021) 

"Our results indicate (1) that seizure outcomes can be retrospectively predicted with excellent accuracy using changes in structural connectivity, and (2) that favorable connectomic changes are associated with an ablation volume involving relatively mesial, anterior, and inferior locations. These results may provide a framework whereby individual pre-operative structural connectomes can be used to optimize ablation volumes and improve outcomes in LITT for mTLE." (Ko AL, et al., 2022) 

The scientific evidence in peer-reviewed literature supports improvement in health outcome for this patient's clinical scenario. 

This has been Food and Drug Administration (FDA) approved several years ago. 

This patient is a good candidate for laser interstitial thermal therapy (LITT). The patient has undergone an adequate workup including SEEG. The seizure onset zone has been localized and this is the most appropriate next step in the treatment of this patient. 

This request is well studied and appropriate. Laser interstitial thermal therapy (LITT) is the best available treatment for this patient at this time. 

Based on the best available literature the requested service, LITT, is likely to be more beneficial than any of the standard treatments/procedures for this patient.                                           

In summary, the denial of inpatient procedure for laser interstitial thermal therapy (LITT), should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments. The risks are less and there is benefit of this procedure.