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

Physician 1: The patient is a 54-year-old female who is requesting authorization for vestibular rehabilitation therapy for the management of dizziness and balance issues post coma and traumatic brain injury. The Health Plan has denied the patients request on the basis that the requested therapy is considered investigational for treatment of the patients condition.The Health Plans denial should be upheld. There is insufficient data demonstrating the benefits of vestibular rehabilitation therapy for treatment of patients such as this patient. The proposed therapy is not likely to result in significant clinical improvement beyond the progress that was made via inpatient rehabilitation following the traumatic brain injury. Therefore, I have determined that the requested therapy is 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 2: The patient was involved in a motor vehicle accident in 1999 resulting in multiple fractures, traumatic brain injury and a coma of approximately one-month duration. Since the accident she has spastic left hemiplegia and post-traumatic organic brain syndrome. The patient has ongoing symptoms of dizziness and balance issues that have not responded to medical management.  The patients provider has recommended vestibular rehabilitation therapy. The Health Plan has denied coverage for the requested therapy on the basis it is considered investigational.The proposed vestibular rehabilitation program is clinically appropriate and indicated for the patient. Though data on the efficacy of vestibular rehabilitation therapy in this clinical setting is lacking, there are no standard therapies that are likely to be effective for this patient. Given the absence of other available modalities, a trial of the requested therapy is medically reasonable and should be authorized. Based upon the information set forth above, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 54-year-old female with a history of dizziness and balance issues since being involved in a motor vehicle accident in 1999, which caused multiple fractures, traumatic brain injury and a one-month coma. The patients provider indicates the patient has not benefited from standard medical management. As such, a trial of vestibular rehabilitation therapy was recommended. The Health Plan had denied authorization for the proposed therapy citing the lack of peer-reviewed data supporting its efficacy.Review of the relevant medical literature reveals limited data regarding the efficacy of vestibular rehabilitation for treatment of the patients condition. One study involving 29 patients did not report any benefit. Another study involving 12 patients indicated there was benefit in particular subgroups of patients but not compared to standard therapies. A third study found improvement in one-leg standing balance, but not in the Romberg test, walking heel to toe, or dizziness measured on the visual analogue scale. None of the available studies provide sufficient justification for the use of vestibular rehabilitation in the treatment of this patient. Therefore, I have determined that the requested therapy is 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.