AIDS HIV: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1: The patient is a 52-year-old male with HIV related lipodystrophy. He is requesting coverage for Serostim injections to alleviate symptoms and side effects relative to fat accumulation including respiratory distress, limited range of motion, and need to modify sitting/sleep position. Prior interventions including diet, exercise, metformin and testosterone provided no benefit. The Health Plan indicates Serostim injections are considered investigational for treatment of lipodystrophy. Given the well-documented morbidity associated with the patient’s abdominal lipodystrophy, a trial of therapy with Serostim is indicated. It does not appear there is an alternative intervention for this patient with a severe condition that continues to worsen despite multiple interventions.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zepbound. The Surmount-1 trial was a phase 3, multicenter, double-blinded placebo-controlled trial looking at over 2500 patients with obesity or who were overweight with one weight-related complication who were prescribed different dosages of tirzepatide (Zepbound) or placebo. The trial showed that participants at various dosages of tirzepatide achieved at least 5% weight reduction in 85% of the participants in the lower medication dose (5 mg weekly) and 91% in the highest dose (15 mg weekly). The mean change in weight across all participants given tirzepatide was -15% at week 72. The Surmount-4 trial by Aronne and colleagues was a randomized controlled trial looking at patients with obesity or overweight on tirzepatide for weight maintenance.

Where the denial was upheld

Physician 1The patient has HIV infection, extensive Kaposi’s sarcoma and Castleman’s disease, which has not responded to standard therapy consisting of three cycles of Cytoxan and Rituxan. The patient has requested authorization for Velcade. The Health Plan has denied this request indicating that the efficacy of Velcade for the patient’s diagnosis has not been shown.Castleman’s disease is a rare condition with few clinical trials available. Velcade has been used successfully in controlled clinical trials for the treatment of refractory multiple myelomas (FDA indication) as well as a variety of other tumor types. Because Castleman’s disease involves uncontrolled growth of lymphoid tissues, it resembles in many ways multiple myeloma, for which Velcade has proven effective.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy excision of excessive skin and subsequent tissue of the buttock tissue grafts and suction-assisted lipectomy of the trunk The submitted documentation fails to demonstrate the medical necessity of the requested panniculectomy .There is no photographic documentation of a panniculus or a report of a panniculus on physical examination. Findings: The physician reviewer found that there is also no complaint of a recurrent rash beneath an abdominal panniculus or of failure of treatment of such a rash. Under these circumstances, the medical information received for review does not support that a panniculectomy is medically necessary. Additionally, there is no functional loss that is documented to be related to an abdominal pannus.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for aids hiv was denied, the published record says the denial is worth fighting.