Anaphylaxis denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for Neffy solution. According to a study, “Patients at a higher risk of anaphylaxis are often prescribed epinephrine intramuscular (IM) autoinjectors because the vast majority of anaphylactic events occur at home or in a community setting. However, epinephrine self-administration via autoinjectors for anaphylaxis is suboptimal because of lack of carriage and needle phobia, which may result in delayed administration or failure to use epinephrine at all. In a study of 190 patients prescribed epinephrine IM autoinjectors, only 30% of those who experienced an anaphylactic event actually used it.” This study found that delays or failure to self-administer epinephrine increase the risk of serious anaphylaxis-related complications.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating the services at issue were not necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient was found by paramedics in anaphylactic shock, likely due to ingestion of shellfish. Documents provided note the enrollee improved with intramuscular epinephrine as well as intravenous fluids and diphenhydramine. The enrollee was subsequently administered intravenous steroids as well. The half-life of intramuscular epinephrine is brief. The medical literature notes the existence of a biphasic reaction to food induced anaphylaxis (FIA) wherein recurrent symptoms occur following the resolution of the initial reaction.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for oral immunotherapy. Findings: Anaphylaxis is a life-threatening hypersensitivity reaction to something in the environment. Onset is sudden and typically dramatic, with respiratory, skin, and gastrointestinal manifestations. There are multiple triggers, including foods, insect stings, and medications. Foods are the most common triggers in the pediatric population. Because anaphylaxis is a medical emergency, treatment must be rapid. Current guidelines agree that epinephrine is the first medication of choice. Second-line treatments include antihistamines (H1 and H2) and glucocorticoids. Oral immunotherapy is a promising therapy for people with allergies. However, it is still under investigation in both children and adults.

A 43-year-old male enrollee requested authorization and coverage of enzyme potentiated desensitization. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollee’s anaphylaxis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plan’s denial on the basis that the requested therapy is not medically necessary.

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 anaphylaxis, then check the rights and deadlines that apply to your plan.