ALS denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for joint manipulation under anesthesia. Catalano and colleagues noted, “The stiff digit may be a consequence of trauma or surgery to the hand and fingers and can markedly affect a patient’s level of function and quality of life. Stiffness and contractures may be caused by one or a combination of factors, including joint, intrinsic, extensor, and flexor tendon pathology, and the patient’s individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Relyvrio and/or Radicava.ALS is a motor neuron degeneration disease primarily in the motor cortex and spinal cord that leads to progressive muscle weakness. The patient in this case has been diagnosed with ALS since June 2023 with the onset of symptoms in February 2021. As noted by government studies in their approval, Relyvrio and Radicava have been demonstrated to be safe and effective medications for the treatment of patients with ALS. These two medications are accepted as the two of three disease-modifying treatments for ALS. In addition, the current medical literature has provided support for Relyvrio and Radicava in the slowing of clinical deterioration in patients with ALS.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Radicava (Edaravone Injection). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s amyotrophic lateral sclerosis (ALS). At issue in this case is whether the requested medication Radicava (Edaravone Injection) is medically necessary for treatment of the enrollee’s medical condition.Amyotrophic lateral sclerosis is a progressive neurological disease that causes degeneration of muscles and leads to weakness with significant morbidity and mortality. The characteristics of the disease have a combination of lower motor neurological problems with upper motor neurological problems. Survival is poor with a median time of three to five years. Edaravone works on free radicals.

Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for Functional Electric Stimulation Cycle Rehabilitation System (FES). The enrollee has spastic cerebral palsy. He was an active individual who was able to ambulate, work, and remain independent. He was diagnosed with C4 amyotrophic lateral sclerosis (ALS) cervical tetraplegia due to transverse myelitis. The enrollee has lost volitional motor function below C4 in his bilateral upper and lower extremities. His light touch sensation and proprioception is absent bilaterally below C4. The enrollee utilizes a standing frame weekly to maintain leg and trunk flexibility. He requires an alternative form of activity therapy since he cannot do this volitionally.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving ALS, then check the rights and deadlines that apply to your plan.