Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Neural Zoomer Plus test. Findings:  The physician reviewer found that Neural Zoomer Plus is an array of neurological autoantibodies offering specific antibody-to-antigen recognition, designed to assess an individuals reactivity to 48 neurological antigens, which may be connected to a variety of neurologically related diseases. Markers measured include demyelinating agents, blood brain barrier disruption, optical and autonomic nervous system disorders, peripheral neuropathy, neuromuscular disorders, brain autoimmunity, brain inflammation, and infections. The following antibodies are tested for neuromuscular disorders: anti-acetylcholine receptors, anti-muscle specific kinase, anti-voltage gated calcium channels, anti-voltage gated potassium channels, and anti-titin. Antibodies for anti-acetylcholine receptors, anti-muscle specific kinase, and anti-titin are found in myasthenia gravis. Bird and colleagues describe myasthenia gravis as a common autoimmune condition and disorder of neuromuscular transmission. The authors explain, The hallmark of the disorder is a fluctuating degree and variable combination of weakness in ocular, bulbar, limb, and respiratory muscles. Weakness is the result of an antibody-mediated, T cell-dependent immunologic attack directed at proteins in the postsynaptic membrane of the neuromuscular junction (acetylcholine receptors [AChR] and/or receptor-associated proteins). The diagnosis of myasthenia gravis can be established by clinical and serologic testing. Bekircan-Kurt and colleagues report that anti-voltage gated calcium channel antibodies are responsible for Lambert-Eaton myasthenic syndrome (LEMS), a rare autoimmune disorder of the neuromuscular junction, which presents with a classical clinical triad of proximal muscle weakness, areflexia, and autonomic dysfunction. Platone and colleagues report that anti-voltage gated potassium channel antibodies downregulate the potassium channels expressed on the peripheral nerve terminal, leading to nerve hyperexcitability. In this case, the provider has recommended a Neural Zoomer Plus test to evaluate the patients muscle weakness, tightness, and spasms. However, the submitted records include laboratory results showing that testing for pertinent markers to evaluate autoantibodies related to muscle symptoms has previously been performed, with normal results. Given that the remaining autoantibody markers in the Neural Zoomer Plus test are not pertinent to the patients reported muscle symptoms, the requested service is not medically indicated. Therefore, a Neural Zoomer Plus test is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology 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.