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

Physician 1: The patient is a two-year-old female with neonatal right-sided hemiparesis. Some degree of improvement has already been achieved with the use of neuromuscular electrical stimulation therapy (e.g., increased mobility). The patients parent has requested authorization and coverage for a neuromuscular electrical stimulation device. The Health Plan has denied this request indicating the requested equipment is considered experimental.Neuromuscular electrical stimulation devices have been shown to be very useful for treatment of patients such as this patient. The device will prevent severe contractures in a developing child such as this patient, and therefore, is medically indicated. The rehabilitation literature is replete with positive results, and the device has proven clinical value. Therefore, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: This case involves a two-year-old female who has right-sided hemiparesis following an intrauterine stroke. Her physician as well as her occupational therapist have recommended the patient use a neuromuscular electrical stimulation device for muscle re-education. The Health Plan has denied authorization for the requested equipment on the basis there is insufficient peer-reviewed published literature to support its use.The patients physician and her occupational therapist have recommended use of a neuromuscular stimulation device. The submitted evidence documents the patient experienced improvement in range of motion with use of a neuromuscular stimulator. Thus, there is documented evidence the requested equipment has been beneficial for this patient. The patient is unlikely to experience the same degree of improvement with standard therapies. Given the recommendations of the patients providers and the observed improvement to date, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. The patient should be re-evaluated in one year.Physician 3: The patient is a two-year-old female with a history of right hemiparesis due to neonatal stroke. She has been receiving occupational therapy to address functional use of her right upper extremity. She has gained active elbow extension, but still lacks supination and has decreased hand function. The patients therapist has recommended a neuromuscular electrical stimulation (NMES) device to improve motor functional use of the right upper extremity.NMES is a tool used by therapists to strengthen agonist muscles in conjunction with stretching of the spastic muscle to reduce tone in the extremity. NMES is different than therapeutic electrical stimulation, which is performed at lower frequencies and longer duration.Though the literature about the benefits of NMES has been mixed, several level I studies have been performed and many show improvement in gross motor function measure as well as in range of motion of the joint evaluated. As such, it is reasonable to believe that an appropriately planned use of NMES can be an acceptable adjuvant treatment in combination with active therapy. Information documented in the treatment plan should include muscles stimulated, frequency applied in Hz, duration of stimulation, the number of sessions required (i.e., two times per day) with a standardized measurement tool, functional goals and a similar plan for follow-up monitoring. The patient should continue to use a NMES device as long as she continues to show functional improvement. Based upon the information set forth above, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.