Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epilepsy

Treatment: code 61736 (Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion)

The insurer denied coverage for code 61736 (Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion)

The denial is overturned
 

This is a young adult with a diagnosis of uncontrolled intractable epilepsy that has been resistant to multiple medications. The treating provider has requested laser treatment for seizures (laser interstitial thermal therapy [LITT]), code 61736, which is under review.

Laser treatment for seizures (LITT) has been proposed as a less invasive treatment option for patients with neurological conditions compared to surgery. Two LITT systems, Visualase and NeuroBlate, have received marketing clearance from the United States Food and Drug Administration (US FDA). 

Per Youngerman BE and other (et al.) (2018), "Twelve patients with  Stereoelectroencephalography (SEEG)-confirmed, non- Mesial temporal sclerosis (MTS) Mesial temporal lobe epilepsy (MTLE) and 18 patients with magnetic resonance imaging (MRI)-confirmed MTS underwent Stereotactic Laser Amygdalohippocampectomy (SLAH). MTS patients were older (median age 50 versus 30 years) and had longer standing epilepsy (median 40.5 versus 5.5 years) than non-MTS patients. Engel class I seizure freedom was achieved in 7 of 12 non-MTS patients (58 percent (%), 95% confidence interval [CI] 30%-86%) and 10 of 18 MTS patients (56%, 95% CI 33%-79%), with no significant difference between groups. Length of stay was 1 day for most patients (range 0-3 days). Procedural complications were rare and without long-term sequelae...

Per Cobourn K, et al. (2018), "These early data demonstrate that sEEG followed by Magnetic resonance-guided laser interstitial thermal therapy (MRgLiTT) can be used safely and effectively to localize and ablate epileptogenic foci in a minimally invasive paradigm for treatment of medically refractory lesional epilepsy in pediatric populations."

Per Gupta et al., (2020), "MRI-guided laser interstitial thermal therapy (MRg-LITT) is an alternative to open epilepsy surgery."

Per the American Society for Stereotactic and Functional Neurosurgery Position Statement on Laser Interstitial Thermal Therapy for the Treatment of Drug-Resistant Epilepsy, "Indications for the Use of MRgLITT as a Treatment Option for Patients With drug resistant epilepsy (DRE) Include All of the Following Criteria:

1.	Failure to respond to, or intolerance of, at least 2 appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy AND

2.	Well-defined epileptogenic foci or critical pathways of seizure propagation accessible by MRgLITT"

This patient is resistant to most medications and needs treatment. Laser treatment for seizures (laser interstitial thermal therapy [LITT]), code 61736 is considered medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for preservice Neurosurgery/Spine service(s); laser treatment for seizures (laser interstitial thermal therapy [LITT]), code 61736 (Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion) is substantiated.