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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a referral to a multidisciplinary outpatient brain injury clinic for the diagnosis and comprehensive treatment plan for a frontal lobe traumatic brain injury (TBI). The enrollees TBI required intensive care unit admission and brain shunt; and then neurological inpatient care. Since the TBI, the enrollees condition has gotten progressively worse with neurocognitive symptoms and disorders. He developed major depressive disorder (MDD) requiring multiple psychiatric admissions for other mental disorders. Review of the record indicates the enrollees clinical management was focused on treating individual conditions rather than a comprehensive approach to treating the neurobehavioral and cognitive sequelae associated with traumatic brain injury (TBI).  To date, there is clear evidence of the potential for long-term neurobehavioral and cognitive sequelae associated with mild-TBI. Based on this enrollees history of TBI that required ICU and brain shunt, it is highly presumed the patients TBI was severe. The medical literature indicates severe TBI is associated with secondary brain injury due to hypoperfusion. Although the association between hypoperfusion and specific cognitive symptoms is generally weak, there is a significant relationship between hypoperfusion of the frontal lobe and executive function. Behavioral disinhibition, depression/anxiety/psychosis, substance abuse and attention/cognitive disorders are the most common syndromes of post-TBI. Consistent with this description, this enrollee presents with personality change, major depressive disorder, attention deficit hyperactivity disorder, and alcohol disorder. A study indicates cognitive and emotional impairments including symptoms of depression and anxiety have been shown to affect the achievement of rehabilitation goals after TBI and are a major cause of disability after TBI. However, since cognitive and emotional impairments are not noticeable initially, it is difficult for other people to understand the severity and problems with which a person with severe TBI has to cope. This article, thus, supports that both screening and follow-up of cognitive function is important for rehabilitation of persons with severe TBI; and these visits should be specific for post-TBI patients, and appropriate instruments should be used to diagnose and measure progress. For example, the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) is an instrument that measures both cognitive and affective disturbances in patients with TBI; and the Glasgow Outcome Scale Extended (GOSE) is an instrument that measures the level of disability and categorization of posttraumatic disability. Based on the review of the record, the enrollee has not received the comprehensive care necessary to appropriately diagnose, treat and monitor progress for his medical conditions specifically associated with his post-TBI history. The medical literature indicates brain injury confers increased sensitivity to the active agents of the central nervous system (CNS). Thus all pharmacological treatment, including antidepressant medications and side effects may be accentuated at lower doses in patients after TBI. It is important in terms of patient safety and treatment efficacy the enrollee is treated by a provider who knows how to treat patients with post-TBI neuropsychiatric sequelae to TBI. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.