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

Physician 1:  This case concerns an 11-year-old male patient with a complex neuropsychiatric problem diagnosed as attention deficit disorder and autism. He has been treated with Metadate with very little improvement and significant side effects. As an alternative to stimulant medications, the patient was treated with EEG neurofeedback from September 2005 through February 2006 and improvement in focus, social skills and anxiety level was noted by his parent. The Health Plan denied the parents request for reimbursement for the therapy, citing the experimental/investigational nature of neurofeedback.EEG neurofeedback continues to be an investigational and experimental treatment modality and its efficacy in the treatment of ADHD and/or autism has not been established through peer-reviewed clinical research.  It appears from the record provided, the patient did not respond well to stimulant medications.  If his parent and provider feel there is a need to explore alternative treatment modalities, there are non-stimulant medications and behavioral approaches available with demonstrated efficacy in the management of ADHD and/or autism.  Therefore, I have determined that the therapy at issue was 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 2:  The patient is an 11-year-old male who a diagnosis of autistic spectrum disorder and attention deficit hyperactivity disorder (ADHD). There were multiple side effects with stimulant medications, and he was treated with EEG neurofeedback from September 2005 to February 2006 an attempt to decrease or discontinue the stimulants. The parents request for reimbursement for the therapy was denied by the Health Plan based upon a determination that such treatment is experimental/investigational.The practice parameters published by the American Academy of Child and Adolescent Psychiatry generically refer to EEG neurofeedback as an unproven approach to the treatment of individuals with ADHD and/or autism. This therapy is at best, an investigational approach to the treatment of patients such as this one. Based on current standards of practice in child and adolescent psychiatry, I have determined that the therapy at issue was 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 3:  This patient is an 11-year-old male who appears to meet DSM-IV TR criteria for autistic disorder. Reviewing the submitted neurotherapy records, there appears to be no objective measure of improvement in the patients condition.  The patients parent has submitted a request for reimbursement for EEG neurofeedback therapy provided from September 2005 through February 2006.  The Health Plan has determined that this therapy remains unproven for the treatment ADHD or autism and denied the requested reimbursement.  Based on a review of the literature, neurofeedback or neurotherapy, is a procedure with questionable clinical value in the treatment of autism or ADHD.  There is no indication that neurofeedback is effective in the treatment of either condition. The recommended treatment approach for autism spectrum disorders is symptomatic, and often includes medical management. As the efficacy of EEG neurofeedback has not been established, I have determined that the therapy at issue was 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.