Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uveitis
Treatment: Infectious Agent Detection by Nucleic Acid (DNA or RNA) Herpes Simples Virus, Quantification (87530)
The insurer denied: Infectious Agent Detection by Nucleic Acid 
(DNA or RNA) Herpes Simples Virus, Quantification (87530)
The denial is overturned.

The patient is an adult male for whom coverage of herpes simplex virus (HSV) quantitative polymerase chain reaction (PCR) testing is the subject of review. Coverage was previously denied by the plan as experimental/investigational. Upon 
appeal, the provider states that the patient presented with features concerning for herpetic uveitis that can be caused by either cytomegalovirus (CMV), herpes simplex virus 1 (HSV1), herpes simplex virus 2 (HSV2) or varicella-zoster virus (VZV) (all herpetic groups of viruses). The features were of potentially blinding ocular inflammation and very high intraocular pressures. An anterior chamber paracentesis was performed to harvest the aqueous humor from the right eye and polymerase chain reaction testing was performed for herpetic viruses (standard of care diagnosis for herpes). The provider cites medical literature defining etiologies of hypertensive uveitis/ocular inflammation caused by herpetic viruses and their detection, and states that such testing was needed to guide therapy.

The health plan should cover the testing performed.

In this case, the patient presented with hypertensive uveitis suspicious for a herpetic etiology. According to the American Academy of Ophthalmology, herpes simplex virus (HSV) associated uveitis is a common cause of unilateral hypertensive anterior uveitis. Herpetic anterior uveitis causes approximately 5-10% (percent) of uveitis cases. Polymerase chain reaction for herpes simplex virus deoxyribonucleic acid (DNA) from an anterior chamber tap may be helpful in diagnosis with a high sensitivity (91.3%) and specificity (98.8). Varicella zoster virus (VZV)-associated uveitis is another a common cause of unilateral hypertensive uveitis. Similarly, analysis of aqueous, and 
sometimes vitreous, samples for viral genome (through polymerase chain reaction) may be helpful, especially in case of uncertain diagnosis or no response to treatment. According to one review (1), the clinical characteristics of herpes simplex virus anterior uveitis can mimic other viral and non-infectious anterior uveitis entities, especially at onset. Aqueous humor analysis for polymerase chain reaction and Goldmann-Witmer coefficient (GWC) can be useful in case of suspected viral uveitis. Similarly, a study (2) compared the clinical value of aqueous humor polymerase chain reaction and serologic tests in patients diagnosed with suspected infectious uveitis. They concluded that aqueous humor polymerase chain reaction can be a valuable diagnostic tool for confirming the infectious etiology in patients clinically diagnosed with uveitis. Polymerase chain reaction had good predictive and diagnostic value for anterior uveitis and panuveitis. Therefore, the requested testing is identified as medically indicated among standard of care as it was clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for the condition and it was required for the direct care and treatment or management of the condition. The condition would be adversely affected if the services were not provided. The service was provided in accordance with generally accepted standards of medical practice.