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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) exposure and response (ERP) therapy, (2) GeneSite blood testing, (3) single-photon emission computed tomography (SPECT) brain scan, and/or (4) transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that (APA) recommends ERP therapy as a first-line treatment of OCD, even for patients with developmental delay. In this clinical setting, the requested ERP therapy is medically indicated for treatment of the patients intrusive urges, obsessions and compulsions, and suicidal and homicidal ideations stemming from his OCD. In this patients case, ERP therapy is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, ERP therapy is clinically appropriate in terms of type, frequency, extent, site, and duration. ERP therapy is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, (1) ERP therapy is medically necessary for the treatment of this patient. Nurnberger and colleagues note that the need for informed genetic counseling in psychiatry is greater than ever before, knowledge in the field is rapidly growing, and genetic education should become an integral part of psychiatric training. However, in its current state, genetic testing is limited in what it can show. The requested GeneSite blood testing would only reveal if the patient metabolizes a certain medication faster or slower based on the hepatic metabolism of the medication. In this case, the patient reports being resistant to taking medications. In this clinical setting, the issue warranting further investigation is the patients psychiatric diagnosis, which is currently presented more as OCD. In this patients case, GeneSite blood testing is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, GeneSite blood testing is not clinically appropriate in terms of type, frequency, extent, site, and duration. GeneSite blood testing is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, (3) GeneSite blood testing is not medically necessary for the treatment of this patient. First and colleagues report that except in the case of neurocognitive disorders, neuroimaging has yet to have a significant impact on the diagnosis or treatment of individual patients in clinical settings. The authors conclude that at this time, the majority of neuroimagings utility remains as a research tool only. While SPECT neuroimaging has been used in psychiatric research, it is unclear which diagnostic biomarkers noted on the SPECT scan have diagnostic or treatment implications, and these biomarkers are inconsistently read by radiologists, making the findings subjective. In this patients case, a SPECT brain scan is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, a SPECT brain scan is not clinically appropriate in terms of type, frequency, extent, site, and duration. A SPECT brain scan is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, (3) a SPECT brain scan is not medically necessary for the treatment of this patient. The U.S. Food and Drug Administration (FDA) approves the use of TMS for the treatment of recurrent and refractory major depressive disorder. In this case, the records document a long history of treatment for psychotic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder, and developmental delay. While the records note suicidal, impulsive, and homicidal urges, these symptoms appear related to his OCD, rather than to major depressive disorder. There is a lack of evidence in current medical literature supporting the use of TMS in the treatment of OCD. In this patients case, TMS therapy is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, TMS therapy is not clinically appropriate in terms of type, frequency, extent, site, and duration. TMS therapy is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, (4) TMS is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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.