Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obsessive Compulsive Disorder.

Treatment: Deep Brain Stimulation surgery (DBS).

The insurer is denied coverage for deep brain stimulation surgery (DBS). 

The denial is overturned. 

The patient is a male with a diagnosis of medically refractory obsessive compulsive disorder. Deep brain stimulation has been advised.

Alonso, et al. states, "Our analysis confirms that DBS constitutes a valid alternative to lesional surgery for severe, therapy-refractory OCD patients. Well-controlled, randomized studies with larger samples are needed to establish the optimal targeting and stimulation conditions and to extend the analysis of clinical predictors of outcome." (1)

Goodman, et al. states, "Overall, the response rates reported by Denys et al. are in line with recent meta-analytic findings (4) showing that DBS is a highly effective intervention for more than 50% of patients with severe, chronic, and treatment-resistant OCD. The current findings from the Netherlands are germane to clinicians and patients in the United States, where an overlapping brain region, the ventral striatum, is approved by the Food and Drug Administration (under a Humanitarian Device Exemption) as a DBS target in the treatment of refractory OCD. While ventral striatum DBS is an important option for intractable OCD, there is room for improvement in outcome rates, magnitude of response, and mitigation of DBS-induced side effects, particularly hypomania." (3)

Senova, et al. states, "Deep brain stimulation (DBS) has been proposed as a reversible and controllable method to treat refractory patients, with meta-analyses showing 60% response rate following DBS, whatever the target: anterior limb of the internal capsule (ALIC), ventral capsule/ventral striatum (VC/VS), nucleus accumbens (NAcc), anteromedial subthalamic nucleus (amSTN), or inferior thalamic peduncle (ITP). But how do we choose the "best" target? Functional neuroimaging studies have shown that ALIC-DBS requires the modulation of the fiber tract within the ventral ALIC via the ventral striatum, bordering the bed nucleus of the stria terminalis and connecting the medial prefrontal cortex with the thalamus to be successful. VC/VS effective sites of stimulation were found within the VC and primarily connected to the medial orbitofrontal cortex (OFC) dorsomedial thalamus, amygdala, and the habenula. NAcc- DBS has been found to reduce OCD symptoms by decreasing excessive fronto-striatal connectivity between NAcc and the lateral and medial prefrontal cortex. The amSTN effective stimulation sites are located at the inferior medial border of the STN, primarily connected to lateral OFC, dorsal anterior cingulate, and dorsolateral prefrontal cortex. Finally, ITP-DBS recruits a bidirectional fiber pathway between the OFC and the thalamus. Thus, these functional connectivity studies show that the various DBS targets lie within the same diseased neural network. They share similar efficacy profiles on OCD symptoms as estimated on the Y-BOCS, the amSTN being the target supported by the strongest evidence in the literature. VC/VS-DBS, amSTN-DBS, and ALIC-DBS were also found to improve mood, behavioral adaptability and potentially both, respectively." (5)

The American Association of Neurological Surgeons suggests use of DBS for OCD for carefully selected patients. They reference an article by Hamani, et al. that states, "This article established evidence-based guidelines on DBS when used to treat patients with OCD. The authors conclude that of the existing studies, in one class I and two class II double-blind, randomized, controlled trials it was reported that bilateral DBS is more effective in improving OCD symptoms than sham treatment. (6)

This service is likely to be more beneficial than any other standard treatment/procedure for this patient.

The carrier's denial of deep brain stimulation surgery (DBS) should be overturned.