Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 56-year-old male who experienced a head injury in July 2003. He showed mild cognitive deficits upon neuropsychological testing. The submitted records indicate the patient received speech therapy. He currently has a mild cognitive deficit. The patient consulted a neuropsychologist who recommended cognitive rehabilitation therapy. The Health Plan has denied authorization for cognitive rehabilitation therapy on the basis that it is considered investigational.Upon review of the submitted records it appears the patients cognitive issues are mild. Cognitive rehabilitation therapy was not ordered by the patients physician who has been directing the patients neurologic care. Cognitive rehabilitation in this setting is unlikely to be more effective than continued standard therapy. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 56-year-old male status post traumatic brain injury with basal skull fractures, subarachnoid hemorrhage, and subdural hemorrhages. Physical sequela is most notable for severe hearing loss in the right ear and mild to moderate hearing loss in the left ear. Cognitive deficits are more debilitating and impacting the patients quality of life. After receiving speech therapy targeting the cognitive aspects of his injury the patient has shown improvement and his speech therapist anticipates further progress. The patient has requested authorization for cognitive rehabilitation therapy. The Health Plan has denied the request on the basis that cognitive rehabilitation therapy is considered experimental.Based upon the provided clinical information and review of the current literature regarding cognitive rehabilitation therapy in traumatic brain injury, it appears the patient may benefit from the requested therapy if he continues to show deficits. However, the submitted information does not include a recent evaluation by the patients neuropsychologist, which indicates the patients current status and level of improvement since the time of the injury. The patient should be re-evaluated by a neuropsychologist as he is approaching one year since the injury. If the results of the re-evaluation indicate the patient has shown improvement from the initial evaluation but continues to experience cognitive deficits, the patients request for cognitive rehabilitation therapy should be reconsidered.Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy at this time. The Health Plans denial should be upheld at this time. However, if upon re-evaluation a neuropsychologist determines the patient has shown improvement from the initial evaluation but continues to experience cognitive deficits, the patients request for cognitive rehabilitation therapy should be reconsidered.Physician 3The patient is a 56-year-old male who experienced a fall in July 2003. The patient sustained skull fractures including basal skull fractures, and subarachnoid and subdural hemorrhages. The submitted information indicates the patient experienced approximately a 90% hearing loss in his right ear and 30% hearing loss in his left ear. In March 2004, a neuropsychologist noted the patient exhibited mild cognitive dysfunction. The patient has requested authorization for cognitive rehabilitation therapy. The Health Plan has denied the request on the basis that cognitive rehabilitation therapy is considered experimental.A review of the published medical literature fails to demonstrate evidence showing the efficacy of cognitive rehabilitation therapy in the treatment of head injury with residual cognitive deficits. There is no evidence that cognitive rehabilitation therapy is likely to be of greater benefit to this patient than standard therapy. The patient should continue to be treated with standard modalities. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.