Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 27-year-old female who experienced ischemic brain injury and coma after a heart transplant for cardiomyopathy. She has received hyperbaric oxygen therapy for her brain injury/palsy and her family and provider consider the treatment beneficial.  The Health Plan deemed the therapy experimental/investigational and reimbursement and future coverage were denied.A search of the relevant medical literature revealed no studies to suggest a benefit from hyperbaric oxygen for persistent deficits related to toxic, ischemic or anoxic encephalopathy. Additionally, the peer-reviewed literature does not demonstrate evidence suggesting efficacy of hyperbaric oxygen in patients following coma. Therefore, I have determined that the requested therapy was/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 2: This patient is a 27-year-old female who is status post heart transplant secondary to cardiomyopathy in 2001. She suffered an anoxic brain injury with resulting spastic quadriparesis and cognitive difficulties. She received a 50-treatment course of hyperbaric oxygen therapy (HBO) with reports of improvement by her provider. The family now requests reimbursement and coverage for further treatment.  The Health Plan considers the HBO therapy experimental/investigational and has denied coverage.Multiple meta-analyses have been performed on data regarding the effectiveness of HBO in brain injury and stroke. They all conclude there is no evidence of a significant therapeutic benefit with HBO for this type of brain injury.  HBO is not indicated for this patients diagnosis.Based upon the information set forth above, I have determined that the therapy at issue was/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 3: The patient is a 27-year-old female who had an apparent anoxic or ischemic brain injury in October 2002 purportedly related to her heart transplant in 2001.  She has residual spasticity and cognitive deficits according to the clinical records, but there are no neurological assessments or neurological studies included. The patient has been receiving hyperbaric oxygen treatments. Clinical notes from her primary care provider indicate an uncertainty as to the patients response to the hyperbaric treatments.  Her parent has requested reimbursement for the therapy already provided and authorization for future therapy. The Health Plan denied the request based on a determination that the therapy was/is experimental/investigational for the treatment of the patients brain injury.The patient apparently has persistent deficits following a presumed anoxic/ischemic brain injury.  It appears that she has had some improvement over the several years since the injury, but neurological studies are not well documented. A search of relevant medical literature revealed no studies that would support this plan of treatment. Hyperbaric treatments are not indicated in this circumstance.  Therefore, I have determined that the therapy at issue was/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.