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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for gene test (methylenetetrahydrofolate reductase mutation testing (MTHFR) for evaluation of the enrollees behavior conditions. The patient has a diagnosis of attention deficit hyperactivity disorder (ADHD). The patients ADHD was initially treated with stimulants which improved his grades. However, the patient had side effects to the medications and so, the stimulants were discontinued. The patient was treated with more natural methods. A methylenetetrahydrofolate reductase (MTHFR) genetic test was ordered by the provider to screen for MTHFR mutation to assist in the treatment of the patients ADHD and behavioral problems. The Health Plan denied the reimbursement for the gene test MTHFR. The Health Plan reported that the services at issue were investigational for the evaluation of this patient. The superior efficacy of the services at issue has not been established in this clinical setting.  This patient underwent gene testing to determine drug metabolizer status.  The records document a diagnosis of ADHD. The MTHFR mutations have been associated with various mental health problems, including bipolar disorder, major depressive disorder, and schizophrenia. However, there have been very small studies asserting a possible correlation between MTHFR mutations and ADHD. There is a lack of randomized controlled trials showing that knowledge of a MTHFR variant improves outcomes. Even if positive, the suggested treatment for MTHFR mutation would be L-methylfolate. However, there are no well-powered, randomized controlled trials suggesting the L-methylfolate treatment for positive MTHFR variants improves ADHD symptoms. The MTHFR mutation gene assay is considered investigational. Even the MTHFR mutation results stated the following interpretation, the utility of MTHFR variant testing is uncertain. Therefore, gene test MTHFR was not likely to have been superior to other standard options for the evaluation of this patients medical condition. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.