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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Neurofeedback (biofeedback) therapy.American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for obsessive-compulsive disorder (OCD) state that when possible, cognitive-behavioral therapy (CBT) is the first line treatment for mild to moderate cases of OCD in children. The practice parameters state that for moderate to severe OCD, medication is indicated in addition to CBT. Neurofeedback and biofeedback are not mentioned as treatment options for OCD in children and adolescents.American Academy of Pediatrics (AAP) clinical practice guidelines for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder (ADHD) state that some nonmedication treatments for ADHD-related problems have either too little evidence to recommend them or have been found to have little or no benefit. The AAP guidelines state that these include mindfulness, cognitive training, diet modification, EEG biofeedback, and supportive counseling. In contrast, the guidelines note that evidence is particularly strong for stimulant medications for ADHD.Researchers reviewed the state of research related to electroencephalographic neurofeedback (EEG NF) and concluded that in the fields of neurology and psychiatry, the therapeutic role of EEG NF currently remains controversial. They concluded that further studies are needed to confirm the effectiveness of EEG NF to treat mental and brain disorders.In this case, the patient is an adolescent who has been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). While the patients parent has mentioned that the patient also has body dysmorphic disorder and autism spectrum disorder, the submitted medical records do not reference either of these disorders. The patients treating psychologist reports that the patient has been seen for five Neurofeedback sessions that have proved to be extremely helpful, and the patients parent has requested prospective authorization and coverage for Neurofeedback (biofeedback) therapy to treat the patient. There is not, however, robust empirical evidence indicating that neurofeedback is effective in treating youth with ADHD and OCD. As noted above, AACAP practice parameters for OCD state that when possible, CBT is the first line treatment for mild to moderate cases of OCD in children, and medication is indicated in addition to CBT for moderate to severe OCD. AAP guidelines also note that evidence is particularly strong for stimulant medications for ADHD. AAP guidelines indicate that some nonmedication treatments for ADHD-related problems, such as EEG biofeedback, have either too little evidence to recommend them or have been found to have little or no benefit. Under these circumstances, the requested Neurofeedback (biofeedback) therapy is not medically necessary to treat the patients conditions.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's conditions. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.