Neurosurgery: 86% of denials overturned

Year by year

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2025 · Medical necessity · age 31–40 Other · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Sprint peripheral nerve stimulation (PNS). In this case, the patient has been diagnosed with chronic scapular winging and…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Sprint peripheral nerve stimulation (PNS). In this case, the patient has been diagnosed with chronic scapular winging and impaired shoulder mobility. The patient has tried and failed treatment with physical therapy and has been measured for a scapular stabilization brace and posture shirt. Physical therapy has resulted in some improvement in mobility and posture; however, adherence to exercises has been inconsistent. The patient does not report pain.Peripheral nerve stimulation, including Sprint PNS, is an established treatment for chronic pain conditions. It is not standard treatment for isolated motor deficits such as scapular winging or impaired shoulder mobility in the absence of pain. Therefore, in this patient without a pain syndrome, PNS is not indicated for the treatment of the patient’s condition. Accordingly, the requested Sprint PNS is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s 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 patient’s medical condition and is knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46154

2. Upheld 2025 · Medical necessity · age 41–50 Other · Injury The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for replacement of a skull bone flap using the patient’s own bone rather than the authorized prosthetic implant made of…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for replacement of a skull bone flap using the patient’s own bone rather than the authorized prosthetic implant made of polyetheretherketone. The patient has a history of traumatic brain injury with subdural hematoma and underwent hemicraniectomy, resulting in a large cranial defect. Cranioplasty is indicated to repair the defect and protect underlying brain tissue. Both autologous bone flap reconstruction and prosthetic materials such as polyetheretherketone are accepted approaches, with literature demonstrating comparable efficacy and long term outcomes. Current evidence does not demonstrate a clear clinical advantage of autologous bone flap over prosthetic materials in this setting. Based on the available medical literature, use of the patient’s own bone flap rather than the authorized prosthetic implant is not supported as medically necessary. Therefore, the requested replacement of the skull bone flap using the patient’s own bone is not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the requested service is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board certified in neurological surgery and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-46118

3. Overturned 2025 · Medical necessity · age 31–40 Craniotomy · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for craniotomy surgery with intraoperative rapid molecular diagnostics tests, isocitrate dehydrogenase (IDH), and FastGlioma. In…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for craniotomy surgery with intraoperative rapid molecular diagnostics tests, isocitrate dehydrogenase (IDH), and FastGlioma. In this case, the patient was found to have a 1cm right-sided contrast-enhancing lesion of the hippocampus in the right temporal lobe. The record establishes that the patient wants to preserve as much healthy brain tissue as possible, with the resection of the tumor. Overall, the craniotomy surgery with intraoperative rapid molecular diagnostics tests, IDH, and FastGlioma is medically appropriate in this clinical setting. As such, the requested craniotomy surgery with intraoperative rapid molecular diagnostics tests, IDH, and FastGlioma are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-45917

4. Overturned 2025 · Medical necessity · age 11–20 Other · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for a functional neuromuscular electrical stimulation (NMES) device for the upper and lower extremities. NMES devices may be…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for a functional neuromuscular electrical stimulation (NMES) device for the upper and lower extremities. NMES devices may be indicated in patients with neurologic injury to improve muscle function, mobility, and overall rehabilitation outcomes when the patient demonstrates the ability to effectively use the device. In this case, the patient has a history of spinal cord injury with associated motor deficits and has demonstrated the capacity to use the requested device for functional benefit. The use of NMES is consistent with accepted standards of rehabilitative care in appropriately selected patients. Therefore, the requested NMES device is medically necessary for the treatment of this patient. Final Result:The reviewer determined that the device is medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications:The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-45803

5. Overturned 2025 · Medical necessity · age 51–64 Other · Mental health Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a vagus nerve stimulation (VNS) therapy system. The medical literature supports the use of VNS for patients with treatment-resistant depression. One study…

   Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a vagus nerve stimulation (VNS) therapy system. The medical literature supports the use of VNS for patients with treatment-resistant depression. One study conducted a five-year observational study comparing patients receiving VNS plus treatment as usual (TAU) to TAU alone. The VNS group demonstrated a significantly higher cumulative response rate (68%) compared to the TAU group (41%). Another review also highlights the efficacy of VNS in patients with highly treatment-resistant depression, noting that VNS offers durable antidepressant effects in select patients. In this case, the patient’s clinical profile is consistent with patients described in the supporting literature. The patient has had a chronic, treatment-resistant course of illness for over two decades. The patient has failed multiple antidepressants, augmentation strategies, and transcranial magnetic stimulation (TMS). Electroconvulsive therapy (ECT) was considered and appropriately declined due to concerns about cognitive impact. The patient has experienced significant functional impairment and was recently hospitalized for a depressive episode. Finally, the patient’s treating psychiatrist supports VNS as the next medically appropriate step. Overall, the requested VNS therapy system is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the requested VNS therapy system is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollee's 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.

   Case MN25-44485

6. Upheld 2025 · Experimental or investigational · age 51–64 Other · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for a Vivistim vagus nerve stimulator. Per the medical records, the patient has a history of ischemic stroke with prior vascular intervention. The patient’s provider has…

   The physician reviewer found that a patient has requested authorization and coverage for a Vivistim vagus nerve stimulator. Per the medical records, the patient has a history of ischemic stroke with prior vascular intervention. The patient’s provider has recommended a clinical trial for a vagal nerve stimulator to address lower extremity weakness and notes spasticity of the left upper extremity, which is suitable for paired vagus nerve stimulation therapy. The U.S. Food and Drug Administration (FDA)-approved indications for the Vivistim vagus nerve stimulator do not include lower limb weakness or spasticity, and current clinical practice guidelines note insufficient evidence to recommend either for or against vagus nerve stimulation as an adjunctive intervention for the rehabilitation of acute and chronic motor deficits. In this clinical setting, given that the requested device is not likely to be more beneficial for the treatment of this patient than standard therapies, such as neuromuscular electrical stimulation, rhythmic auditory stimulation, or botulinum toxin, for patients with focal spasticity, a Vivistim vagus nerve stimulator is not likely to be more beneficial for the treatment of the patient's condition than any available standard therapy..Findings: Two of the three reviewers found that the requested Vivistim vagus nerve stimulator is not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested device is not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: Reviewers 1 and 2 are board-certified in physical medicine and rehabilitation and are actively practicing. Reviewer 3 is board-certified in physical medicine and rehabilitation with subspecialty certifications in pain medicine and brain injury medicine and is actively practicing. The reviewers are experts in the treatment of the patient's 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.

   Case EI25-46310

7. Overturned 2025 · Experimental or investigational · age 41–50 Other · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the SPRINT peripheral nerve stimulation (PNS) system.The requested SPRINT PNS therapy is medically appropriate for this patient…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the SPRINT peripheral nerve stimulation (PNS) system.The requested SPRINT PNS therapy is medically appropriate for this patient and is likely to be more beneficial than continued standard therapy for the treatment of complex regional pain syndrome. The patient’s clinical presentation and prior care align with accepted indications for PNS use. The patient has persistent focal neuropathic pain in a well defined peripheral nerve distribution with allodynia and functional impairment. The patient’s symptoms have persisted despite exhaustive conservative modalities, targeted nerve blocks, and a sympathetic block. Temporary 60 day PNS is designed for focal peripheral nerve pain when noninvasive therapies have failed and before committing to additional permanent implants. The evidence supports the meaningful and durable benefits of 60 day percutaneous PNS for chronic neuropathic pain syndromes. Furthermore, consensus guidance supports PNS in carefully selected patients and recognizes 60 day PNS as a less invasive, reversible option. This patient has a lumbar spinal cord stimulator (SCS) and continues to experience residual focal ankle and foot pain. Thus, the SPRINT PNS targeting the peripheral branches is a guideline concordant next step before considering permanent neuromodulation or escalation of pharmacotherapy. Accordingly, the requested SPRINT PNS system is likely to be more beneficial for the treatment of the patient than any available standard therapy.Findings: Two of the three reviewers found that the requested device is likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result: The reviewers determined that the requested device is likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: Reviewer 1 is board-certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Reviewer 2 is board-certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Reviewer 3 is board-certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the patient’s medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case EI25-46140

8. Overturned 2025 · Experimental or investigational · age 21–30 Other · Skin The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral endoscopic lumbar sympathectomy (ELS). Bilateral ELS is primarily indicated for patients with severe, refractory…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral endoscopic lumbar sympathectomy (ELS). Bilateral ELS is primarily indicated for patients with severe, refractory plantar hyperhidrosis who have not responded to conservative treatments. The procedure is highly effective, with symptom resolution rates typically above 90% and significant improvements in quality of life reported by most patients. ELS is also frequently performed after thoracic sympathectomy in patients with combined palmoplantar hyperhidrosis or persistent plantar symptoms, as is the case with this patient. All told, the requested bilateral ELS is likely to be more beneficial for the treatment of the patient’s condition than any available standard therapy.Findings: Three of the three reviewers found that the requested service is likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested service is likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: Reviewer 1 is board-certified in general surgery and is actively practicing. Reviewer 2 is board-certified in general surgery and is actively practicing. Reviewer 3 is board-certified in general surgery and is actively practicing. The reviewers are experts in the treatment of the patient's 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.

   Case EI25-45942

9. Overturned 2025 · Experimental or investigational · age 11–20 Other · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary:The parent of a patient has requested authorization and coverage for laser interstitial thermal therapy (LITT) for insular cortical dysplasia. LITT is an established minimally…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:The parent of a patient has requested authorization and coverage for laser interstitial thermal therapy (LITT) for insular cortical dysplasia. LITT is an established minimally invasive treatment option for medically refractory focal epilepsy and is supported by clinical literature demonstrating meaningful rates of seizure reduction or freedom in appropriately selected pediatric patients. Clinical guidelines support surgical intervention when seizures are not adequately controlled with antiepileptic medications. In this case, the patient has failed multiple medication trials and previously underwent ablation with only temporary seizure control, suggesting persistent epileptogenic focus rather than treatment ineffectiveness. LITT offers a targeted approach with a favorable safety profile and lower morbidity compared to open surgical alternatives, particularly in eloquent brain regions such as the insula. Based on the patient’s clinical course and supporting evidence, the requested LITT is likely to be more beneficial than any available standard therapy.Findings:The reviewers found that the requested procedure is likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result:The reviewers determined that the requested procedure is likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications:The reviewers are board-certified in neurology with special qualifications in child neurology and epilepsy and are actively practicing. The reviewers are knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case EI25-45875

10. Upheld 2025 · Experimental or investigational · age 41–50 Other · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the Sprint peripheral nerve stimulation (PNS) system. While PNS has been utilized for various peripheral nerve conditions…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the Sprint peripheral nerve stimulation (PNS) system. While PNS has been utilized for various peripheral nerve conditions, there is insufficient support in the peer-reviewed literature demonstrating a significant benefit in pain reduction and functional improvement. In this clinical setting, PNS is unlikely to be more beneficial for the treatment of the patient’s condition than standard therapies such as medication management or physical therapy. Therefore, the Sprint PNS system is not likely to be more beneficial for the treatment of the patient’s condition than available standard therapy. Findings: Two of the three reviewers found that the requested Sprint PNS system is not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested service is not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board-certified in anesthesiology with subspecialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the patient’s 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.

    Case EI25-44947

11. Upheld 2025 · Experimental or investigational · age 41–50 Other · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for implantation of a SPRINT peripheral nerve stimulation (PNS) system. The majority of studies of PNS on complex regional pain…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for implantation of a SPRINT peripheral nerve stimulation (PNS) system. The majority of studies of PNS on complex regional pain syndrome are case series or reports, and the quality of these studies is limited. Sympathetic nerve blocks are the first-line interventional treatment for complex regional pain syndrome, and for refractory cases, targeting the epidural space with opiates, local anesthetics, and/or clonidine is an option. In this clinical setting, current medical literature does not support PNS as likely to be more beneficial than available standard treatments for this patient’s symptoms. Therefore, the SPRINT PNS system is not likely to be more beneficial for the treatment of the patient’s condition than any available standard therapy. Findings: Two of the three reviewers found that the implantation of a SPRINT PNS system is not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested service is not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: Reviewers 1 and 3 are board-certified in anesthesiology with subspecialty certification in pain medicine and are actively practicing. Reviewer 2 is board-certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the patient’s 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.

    Case EI25-44786

12. Upheld 2024 · Medical necessity · age 31–40 Other · Injury Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a spinal cord neurostimulator. This patient presents with paraplegia and has failed previous interventional pain therapies. He has been referred for spinal cord…

    Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a spinal cord neurostimulator. This patient presents with paraplegia and has failed previous interventional pain therapies. He has been referred for spinal cord stimulation to treat chronic pain from the underlying condition. There is currently inadequate data in the medical literature to demonstrate benefit from this therapy for this condition. The current evidence is restricted to small case reports which lack the power to confirm safety and efficacy of the therapy for this medical indication. For these reasons, the requested spinal cord neurostimulator is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s 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.

    Case MN24-42314