Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cerebrospinal fluid leak

Treatment: surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak

The insurer denied coverage for surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak

The denial is upheld

The request is to evaluate whether a surgical procedure to close a vascular opening or fistula in the spinal vein/ cerebral spinal fluid (CSF) network to prevent continuing cerebrospinal fluid (CSF) leak is considered more beneficial for this patient's diagnosis.

 She had a CSF venous fistula and underwent paraspinal vein embolization.

This surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network, to prevent continuing cerebrospinal fluid (CSF) leak is not supported by literature to have improved health or improved outcomes.      

The surgical procedure to close a vascular opening, or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak does not have final approval from the appropriate regulatory bodies for this diagnosis, as it is not the standard of care.     

This patient is not a good candidate for surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak, since there is lack of evidence of improved outcomes for this procedure.     

The surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak was not the best available treatment for this patient.     

As above, there is lack of evidence to support the procedure, the risks are increased.     

The requested service would not likely to be more beneficial than any of the standard treatments/procedures for this patient. There have been no large trials conducted to support this.

"We report a consecutive case series of patients who underwent transvenous embolization of the paraspinal vein, which was draining the CSF-venous fistula, for treatment of spontaneous intracranial hypotension. These are the first-ever reported cases of this treatment for CSF-venous fistulas. All patients underwent spinal venography following catheterization of the azygous vein and then selective catheterization of the paraspinal vein followed by embolization of the vein with Onyx. All patients had improvement of clinical and radiologic findings with 4 patients having complete resolution of headaches and 1 patient having 50% reduction in headache symptoms". (Brinjikji W, et al., 2021).

In summary, the denial of a surgical procedure to close a vascular opening or fistula in the spinal vein/cerebral spinal fluid network to prevent continuing cerebrospinal fluid (CSF) leak  and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are increased over standard treatments.