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

The patient is a 13-year-old male who was diagnosed with attention deficit disorder (ADD) approximately six years ago. He also has a history of vocal and motor tics as well as obsessive behavior. A SPECT scan performed on 3/18/04 demonstrated brain trauma with decreased left and right anterior pole and decreased posterior medial cerebellar profusion as well as parietal lobe dysfunction. The patients parent has requested reimbursement for the SPECT scan. The Health Plan has denied coverage stating the SPECT scan at issue is considered experimental.SPECT brain scans are not routine in the evaluation of attention deficit disorder. Even with the history of problems at birth and fetal distress, a SPECT scan is not used except on a research basis. The standard of care for ADD does not include SPECT scanning. Furthermore, the physicians notes do not indicate the use of any of the recommended medications found in the SPECT scan report. Thus, it appears the SPECT scan did not affect the management of this patient. Based upon the information set forth above, I have determined that the SPECT scan at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 13-year-old male who experienced a traumatic brain injury as the result of complications at birth. The patient has attention deficit disorder, obsessive behavior, and motor and vocal tics. He has been evaluated clinically by a psychiatrist who confirmed evidence of a traumatic brain injury. A SPECT scan was performed in March 2004. A request has been made for reimbursement for the SPECT scan.SPECT scanning is most useful and indicated for patients who are being evaluated for neurosurgical procedures. Rather than a SPECT scan, an EEG and CT scan, would have been more useful in the evaluation and treatment of this patient. The drug treatment recommended by the psychiatrist for the patient did not depend upon the results from the SPECT scan. Treatment for this patient should be based upon his clinical condition. Therefore, I have determined that the SPECT scan at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 13-year-old male with ADHD. He underwent a SPECT scan in March 2004. The patients provider indicates the SPECT scan helped with evaluation of the patients medical condition by determining brain damage secondary to birth. The Health Plan has denied reimbursement for the SPECT scan at issue on the basis it is considered experimental.SPECT scanning is a specialized procedure that is rarely used in routine evaluations. It has been used experimentally with ADHD, mostly to look at dopamine transport in the brain. The patients provider indicates the SPECT scan helped with treatment by determining brain damage secondary to birth. There is no evidence ADHD is related to brain damage, but it can follow head trauma (Toft, et al.). There is a hypothesis that perinatal injury might cause ADHD, but no proof to date. There is no evidence that ADHD is secondary to perinatal trauma. Furthermore, there is no evidence that SPECT scanning for ADHD is beneficial. Therefore, I have determined that the SPECT scan at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.