Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1:  The patient is a 12-year-old male with diagnoses of attention deficit disorder (ADD), Aspergers syndrome and oppositional/defiant disorder. He was treated with biofeedback therapy from January 2004 through July 2004. The record also indicates the patient was prescribed Adderall in 2003. The parents request for reimbursement for the therapy provided from March 2004 through May 2004 was denied by the Health Plan citing the experimental/investigation nature of neuro/biofeedback therapy for the treatment of ADD.The use of neuro/biofeedback to treat ADD and other related conditions is not considered standard practice by either the American Academy of Child and Adolescent Psychiatry or the American Academy of Pediatrics. The latter organization lists EEG biofeedback among the unproven treatments for attention deficit disorders. While there is a note indicating that the patient was treated with Adderall in the past, there is no evidence in the record that other more commonly recognized treatments were tried and found ineffective. On the basis of these facts, I have determined that the therapy at issue was 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 case involves a 12-year-old male patient who has been diagnosed as having attention deficit disorder (ADD), oppositional/defiant disorder (ODD), and Aspergers syndrome. He was prescribed Adderall in 2003. From January 2004 through July 2004 he received neuro/biofeedback therapy at a center specializing in such treatment. The therapy provided from March 2004 through May 2004 is in dispute; the Health Plan having classified this approach as experimental/investigational and denying the parents request for reimbursement.Neuro/biofeedback therapy is not the standard of care for the treatment of ADD or ADHD in children and adolescents.  The safety and efficacy of this therapy has not been established through double-blind, independent, peer-reviewed studies. Many other  standard treatment modalities exist which are readily available and have been shown to be effective in appropriately controlled studies. Neuro/biofeedback therapy is not generally acknowledged as a valid treatment for attention deficit disorders by practitioners in the field of child and adolescent psychiatry.  Based upon the information set forth above, I have determined that the therapy at issue was 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 12-year-old male who underwent psychological evaluation in December 2002 which confirmed diagnoses of Aspergers syndrome, oppositional/defiant disorder (ODD) and attention deficit disorder (ADD). He received neuro/biofeedback therapy from January through July of 2004. The Health Plan denied coverage for the therapy provided from March 2004 through May 2004 and his parent is now requesting reimbursement for the costs incurred.A review of the literature on neuro/biofeedback from 2002 through the present indicates continued controversy regarding the indications for the therapy and its efficacy. The therapy is most commonly applied and believed to be effective in situations where stress is a factor. The utilization of biofeedback to decrease the symptoms of an attention deficit disorders is described in the literature only as a secondary treatment if medication and/or behavior modification are not sufficiently effective. There is no reference in the literature to neuro/biofeedback as a treatment for Aspergers syndrome or ODD. Neuro/biofeedback would not appear to be the most appropriate treatment in this clinical situation and the records provided for review fail to demonstrate any improvement in the patients symptoms. Therefore, I have determined that the therapy at issue was 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.