Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obsessive Compulsive Disorder.
Treatment: Deep Brain Stimulation surgery (DBS).
The insurer is denied coverage for deep brain stimulation surgery (DBS). 
The denial is overturned. 

This is a male patient with a diagnosis of Obsessive Compulsive Disorder (OCD) demonstrated by severe obsessive compulsive symptoms.. He reportedly feared that if he did not force breathing he would asphyxiate. He reportedly tried multiple serotonin reuptake inhibitors, tricyclic antidepressants, atypical antipsychotic medications, and several experimental medications, as well as transcranial magnetic stimulation (TMS). He did not have sustained improvement. His provider, who is reportedly a leading international expert on OCD had requested a deep brain stimulation (DBS) for the treatment of OCD. 

The FDA has approved this therapy for the management of chronic, severe, treatment resistant obsessive compulsive disorder. It has been designated a Humanitarian Use Device (HUD number 05-0149) by the FDA and has been approved by the FDA under the Humanitarian Device Exemption (HDE number H050003) for the treatment of chronic severe, treatment resistant obsessive compulsive disorder in adult patients who have failed at least 3 serotonin reuptake inhibitors. This patient reportedly failed multiple serotonin reuptake inhibitors, tricyclic antidepressants, atypical antipsychotic medications, and several experimental medications, as well as transcranial magnetic stimulation (TMS), and also cognitive behavioral therapy and psychotherapy. The deep brain stimulation therapy is delivered by an implanted neurostimulator implanted near the collarbone. Electrical stimulation is sent through a thin, flexible lead that is precisely placed in the anterior limb of the internal capsule with one lead placed on each side of the brain. Stimulation of these areas of the brain may aid in the management of some of the uncontrolled symptoms of chronic, severe, treatment resistant OCD. Also, according to the New England Journal of Medicine, deep brain stimulation therapy was a proposed therapeutic option for the treatment of severe obsessive compulsive symptoms. In a 10 month crossover double blind multicenter study it showed that the YBOCS score for obsessive compulsive symptoms was lower after sham stimulation. The findings suggested that stimulation of the subthalmic nucleus may decrease symptoms of severe forms of obsessive compulsive disorder.

This patient was considered a good candidate for deep brain stimulation therapy as he had severe obsessive compulsive symptoms that did not respond to multiple pharmacotherapy trials and multimodal treatment. He tried many different medications including different classes of medications for the treatment of obsessive compulsive disorder without reported efficacy. Deep brain stimulation therapy was considered to be more beneficial than other standard treatments at that time for the treatment of this patient's obsessive compulsive symptoms and the best available treatment option for this patient at the time. Deep brain stimulation therapy had FDA approval for the treatment of chronic, severe, treatment resistant obsessive compulsive disorder under the humanitarian device exemption as well. 

Deep brain stimulation therapy (DBT) for the treatment of obsessive compulsive disorder in this patient is likely to be more beneficial than any other standard treatment.

The carrier's denial of deep brain stimulation surgery (DBS) should be overturned.