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

Physician 1: The patient is a 39-year-old female with depression and a stated 16-year history of mood swings, suicidal ideation and poor functioning. She indicates a diagnosis of bipolar disorder and reports that since 2002 her level of functioning has been dramatically improved with a series of EEG biofeedback procedures.  The patient describes improved performance and a reduced need for medications since the therapy began.  She is no longer on Lexapro and her Lamictal dosage has been decreased. The patient also reports a history of migraine headaches that may be related to her medications.  She has requested authorization and coverage for additional EEG biofeedback/neurofeedback therapy.  The Health Plan has denied her request based upon a determination that the therapy is experimental/investigational in this clinical setting.EEG biofeedback/neurofeedback therapy remains poorly studied and its efficacy is totally unproven. The therapy is most commonly used for the treatment of headaches alone, but treatment outcomes are still uncertain. Clearly EEG biofeedback has not been proven to be an effective treatment for bipolar disorder.  In this case there are strong suggestions of underlying placebo factors, as the patient clearly spurns treatment with medications. The therapy has not gained widespread acceptance in the psychiatric community either as a primary or an adjunctive treatment for patients in this clinical situation.  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 is a 39-year-old female who began treatment with her current psychiatrist in December 2000 for bipolar disorder, type II. She was initially treated with Depakote and Celexa, and it was later determined that she functioned best on Lamictal and Lexapro. Over time, she received EEG biofeedback therapy and at the patients request, her Lexapro 20mg was discontinued and her Lamictal was reduced from 25mg twice per day to 25mg every other day. The patient reported that with the noted medication reduction and the biofeedback she felt better than she had felt in some time.  A review of the psychiatric notes indicates the patient has undergone a number of biofeedback treatments during which time her mood elevated. Due to persistent complaints of fatigue, the patient was also provided with samples of Provigil and underwent a sleep study. The sleep study did not reveal any anomalies of note and concluded, her overestimate of total sleep times suggests an element of sleep-state misperception. Parenthetically, her total sleep times were approximately 6 hours.The patient would like to continue with EEG biofeedback and has submitted a request for authorization of additional therapy.  The Health Plan considers this an experimental/ investigational therapy and has denied coverage.Unfortunately, the enclosed records hold no more than a thumbnail sketch of the patients history of bipolar disorder, type II, and her desire to reduce her medications. It is not possible to fully understand the course of her mood disorder and its treatment over time. Nonetheless, her elevation in mood may not be secondary to the biofeedback itself, but rather to hypomania secondary to too little Lamictal.  Additionally, there is a suggestion of underlying character pathology with the escalation of grandiosity as noted above. Lamictal 25mg twice a day or every other day is simply too small a dose to have any effect on mood, either positive or negative.  Subjectively, the patient often felt fatigued and reported that she was sleeping excessively. This was not borne out in the sleep studies but rather, the exact opposite was shown to be the case.  She was only sleeping about 6 hours and with a fairly good sleep efficiency of 84%. All told, her bipolar disorder appears complicated by underlying character pathology for which continued psychotherapy is indicated and from a purely medicinal standpoint, she is under treated. Based upon the information set forth above, 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 3:  The patient is a 39-year-old female with an apparently long history of mood instability, diagnosed as bipolar disorder in 1992. According to the documents provided, the patient began EEG biofeedback (neurofeedback) treatments in 2002 and has not had any serious mood swings since treatment began. Lamictal every other day is her only current medication. The patient apparently suffers from migraines, which are also relieved by the EEG biofeedback. The patient reported her attention problems and distractability were also much improved. The patient now requests authorization and coverage for further treatment with EEG biofeedback. The Health Plan considers the therapy experimental/investigational and has denied her request.Although neurofeedback has not gained widespread acceptance as an adjunctive treatment for bipolar disorder, it apparently did improve this patients symptoms and her ability to function more normally in her life. The evidence is well documented that she did not do as well utilizing more standard treatments.  Therefore, 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.