Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old female with reported Lyme Neuroborreliosis. She had an initial SPECT scan in 2002, which showed an extensive hypoperfusion pattern predominantly in the frontal and temporal lobes and to a lesser degree in the parietal and occipital lobes. A repeat SPECT scan in May 2004 showed marked improvement of the hypoperfusion pattern in the temporal, frontal and parietal lobes since 7/18/02. In the interim the patient received nine months of ceftriaxone therapy. No evidence has been provided regarding the serologic or cerebrospinal fluid status of the patient. No exam findings have been submitted as to her neurologic deficits and there is no information regarding her neurocognitive function. A request has been made for reimbursement for the repeat SPECT scan performed in May 2004. The Health Plan indicates the SPECT at issue was not medically necessary for evaluation of the patients medical condition. SPECT scanning is one of several imaging methods to evaluate neurologic function. It specifically evaluates cerebral blood flow to various regimens of the brain. Hypoperfusion of cerebral lobes is a nonspecific finding, which may be consistent with neurocognitive dysfunction, dementia, Pick disease and Neuroborreliosis. A positive SPECT scan does not make a diagnosis of Neurologic Lyme disease. The study should be used in conjunction with other evidence (examination, laboratory confirmation, other imaging studies) to render a diagnosis of Neuroborreliosis. The literature does demonstrate improvement in SPECT scan cerebral perfusion following a three-week course of antibiotic in documented Neuroborreliosis (Logigian, et al.). In the case of this patient, the initial SPECT scan was appropriate to help document neurologic involvement of a disease process. In conjunction with other clinical evidence for Neurologic Lyme disease, this study can help determine if a particular therapy is of necessity. In the setting of a clinical study, a repeat SPECT scan following standard treatment of Neurologic Lyme disease is reasonable to further investigate the reliability of SPECT scanning. It is not helpful in individual cases, because of its nonspecific findings. An abnormal SPECT scan does not make the diagnosis of Neurolgic Lyme disease and improvement in the scan two years later following an extended course of antibiotic therapy does not improve treatment efficacy. Rationale for an imaging study, laboratory test or procedure is based on the study results guiding further treatment. The decision to treat is based on the reliability, specificity and sensitivity of a particular test and its relevance in further clinical decision making as demonstrated in the literature. A repeat SPECT scan does not meet these criteria in this particular case. Since the initial findings were not diagnostic of Neurologic Lyme disease, an improvement in these findings does not necessarily correlate with treatment efficacy. Furthermore, the rationale for repeating the SPECT scan was to assess the need for further therapy. The patient received nine months of intravenous therapy with ceftriaxone. There is no double blind, placebo-controlled trial in peer-reviewed literature, which demonstrates the efficacy of such therapy beyond three weeks for the treatment of any stage of Lyme disease (Klempner, et al.). Based upon the information set forth above, I have determined that the SPECT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plan denial should be upheld.