Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1:  This case concerns a 13-year-old male with Tourettes syndrome and obsessive-compulsive behavior. The patient has been tried on various medications without significant benefit.  He underwent deep brain stimulation in July 2006. The Health Plan has denied coverage for the procedure on the basis that it is considered investigational for treatment of Tourettes syndrome.Tourettes syndrome is a most difficult neuropsychiatric syndrome. It can be treated with a variety of combinations of medications with moderate success, as suggested and recommended recently by the Tourettes Syndrome Association in New York.  Presently, as cited in the submitted literature, deep brain stimulation is definitely experimental/investigational and may lead to serious unwanted and potentially fatal results. Given the uncertainty surrounding the procedure and its long-term effects, it cannot be recommended at this time. For these reasons, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2:  The patient is a 13-year-old male with severe Tourettes syndrome and obsessive-compulsive disorder. He has been tried on several standard medications without response. He was evaluated by a provider who recommended deep brain stimulation. He underwent the proposed treatment and his parents are now seeking reimbursement from the Health Plan.Deep brain stimulation for the treatment of Tourettes syndrome remains experimental and the likelihood of success is unpredictable. There is a lack of controlled, blinded trials of deep brain stimulation for treatment of the patients condition. Deep brain stimulation therapy remains an unproven procedure without established efficacy in this setting and was not likely to be superior to standard therapy. Based upon the information set forth above, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  The patient is a 13-year-old male with a history of severe Tourettes syndrome. He received pharmacological interventions but continued to have severe symptoms that limited his attendance in school and caused difficulty in controlling his emotions.  He continues to perform well in school but has difficulty reading due to the head tics. He also reported severe headaches that occurred on a daily basis. In addition, there is a report of difficulty in hearing. He was evaluated at a neurology clinic with the recommendation for deep brain stimulation to control his symptoms. The patients parents are requesting reimbursement for the procedure, which was performed in July 2006. The Health Plan has denied this request citing the investigational nature of the procedure.The patient was highly impaired in his ability to function and also had symptoms of diminished hearing and headaches that are not commonly associated with Tourettes syndrome. The submitted documentation does not demonstrate that all available treatment options had been exhausted prior to surgical intervention. Furthermore, the available scientific evidence regarding deep brain stimulation is not sufficient to establish the clinical utility of the procedure for Tourettes syndrome. At this point in time, adequate data supporting the procedure for treatment of the patients condition is lacking. Accordingly, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.