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

Physician 1This patient is an 11-year-old female who has progressive dystonia secondary to DYT-1 genetic defect. She has pursued standard non-surgical treatment including Botox, Artane, Baclofen, and Klonopin with limited benefit. The patients providers have recommended deep brain stimulation evaluation and treatment. The Health Plan has denied authorization for deep brain stimulation therapy on the basis that it is considered experimental.Upon review of the submitted clinical information and the medical literature regarding deep brain stimulation therapy there is sufficient evidence to support the conclusion that deep brain stimulation therapy is likely to be more beneficial for this patient than standard therapy. The submitted literature demonstrates that deep brain stimulation has benefited some patients with progressive dystonia unresponsive to standard therapy. The clinical evidence demonstrates that the patient has not benefited from standard therapy. Deep brain stimulation therapy offers the best chance of a positive outcome for this patient. 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.Physician 2The patient is an 11-year-old female who has DYT-1 genetically related dystonia. Standard therapy has not been effective for the patient. The patients providers have recommended consultation with a neurosurgeon for deep brain stimulation therapy. The Health Plan has determined that deep brain stimulation therapy is experimental in nature.There is not clear evidence supporting the efficacy of deep brain stimulation therapy for treatment of DYT-1 genetically related dystonia. 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 therapy without established efficacy and is not likely to benefit the patient. Therefore, I have determined that the requested procedure 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 3The patient is an 11-year-old female with genetically determined dystonia, a progressive neurological disorder that affects all four limbs, and is difficult to treat with medications aimed at movement disorders. The patient has been tried on Artane, Baclofen, Sinemet, Klonopin, and Botox without success. It has been proposed that the patient undergo deep brain stimulation therapy. The Health Plan has denied authorization for the requested therapy on the basis that it is considered experimental.There is evidence to suggest that deep brain stimulation therapy is likely to be of greater benefit for the treatment of chronic, progressive neurological disorders such as dystonia, Parkinsons disease, and other movement disorders than standard therapy. The submitted records demonstrate the patient has failed standard therapy. The drugs that have been prescribed for the patient are usually ineffective and poorly tolerated by patients with generalized dystonia. Deep brain stimulation appears to be the only remaining treatment for this patient at this time that is likely to be of benefit. 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.