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

Physician 1: The patient is a 47-year-old female who has experienced intractable seizures since childhood. A large number of anti-seizure medications have been tried without significant improvement. The patient is contemplating neurosurgery to ablate the seizure focus. Prior to surgery, it has been recommended that she undergo magnetoencephalography (MEG). The Health Plan has denied authorization for the requested diagnostic procedure on the basis that it remains investigational at this time.Review of the medical literature reveals that the clinical usefulness of MEG in this setting has not yet been established. MEG is a relatively new diagnostic procedure and has not been fully refined. To date, the success rate has not been impressive. As such, it is not likely that MEG will have clinical value in the evaluation of this patients long-standing seizure problem. Therefore, I have determined that the requested diagnostic procedure is 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 47-year-old woman with intractable epilepsy who is requesting magnetoencephalography (MEG) to enhance epilepsy focus determination. The patient has undergone all other forms of non-invasive testing and deep electrode studies are being contemplated. The patients neurosurgeon has recommended MEG prior to electrode implantation in order to reduce the need for placement of numerous depth electrodes. The Health Plan indicates MEG is considered investigational and therefore, has denied authorization for the procedure.This patient has intractable and life threatening epilepsy. Epilepsy surgery is a reasonable and indicated procedure for this patient. There is growing support for MEG and it is becoming a standard diagnostic procedure at major epilepsy surgery centers. MEG may reduce the risk of deep electrode studies that are necessary pre-operatively and therefore, is likely to have a positive impact on the clinical outcome. Based upon the information set forth above, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Physician 3: The patient is a 47-year-old woman with lifelong epilepsy that is medically refractory.  Epilepsy surgery is under consideration and her EEGs showed conflicting findings.  For surgery to be effective, the epileptogenic focus must be identified and if possible, resected. Depth electrodes with invasive monitoring may be needed, but magnetoencephalography (MEG) has been recommended as a noninvasive test that may reduce the amount and risk of invasive testing.  The patients request for authorization has been denied due to the Health Plans determination that the diagnostic procedure is experimental/ investigational.As spatial and temporal resolution has improved, MEG has shown increasing benefit in localizing epileptic lesions.  Its use is non-invasive and the procedure may improve patient safety and outcomes resulting from lesion resection.  Data on its correlation with lesions is early, but latent data supports its value and suggests it may be more accurate than EEG.  Therefore, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, and the Health Plans denial should be overturned.