Asthma denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pollen and allergy injections performed weekly for treatment of the enrollee’s allergic rhinitis and asthma. Findings: The physician reviewer found that based on the available documentation, the service of immunotherapy dosed at once weekly intervals meets the current criteria for medical necessity and is within the standard of care for providing immunotherapy injections to a patient who is symptomatic with asthma and allergic rhinitis. Review of the record shows sufficient documentation to support the increased dosing. There was allergy skin testing done with positive findings for several allergens. Clinic notes from provider indicate that the patient was actively taking multiple medications for rhinitis and asthma.

The patient is a 61-year-old female with reactive airway disease, IgE mediated rhinitis, chronic sinusitis and seasonal and perennial allergies related to mite, mold and animal dander. She has moderate to severe asthma which is steroid dependent and her condition is deteriorating. The patient also has an evolving depression that is situational, secondary to her chronic allergic disease and its effect on her lifestyle and well-being. Her provider’s note of July 2006 indicates she is broadly allergic, mostly housebound and unable to tolerate therapeutic dosages of immunotherapy. The proposed treatment involves stabilization with Xolair over several months followed by immunotherapy. If the immunotherapy is better tolerated and she is able to reach maintenance status, the Xolair could be tapered off after six to twelve months.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollee’s asthma. Findings: The physician reviewer found that the data supports the short and long term benefits of bronchial thermoplasty for patients with severe asthma. However, in this patient’s case, it is uncertain what this patient’s asthma regimen encompasses. The documented medications include a combination of rescue inhalers, which typically controls most asthmatics. Further, it appears if the patient’s predominant issue is dyspnea and pleuritic chest pain, an uncommon presentation in asthma that is reported to be unimproved in the face of steroids. There is a single indication that her regimen was expanded to include an antimuscarinic (Spiriva) and a Leukotriene antagonist, both common medications to trial in refractory asthmatics.

The patient is a 54-year-old female with a history of asthma and allergies. The patient’s provider indicates the patient has specific IgE disease with a pre-Xolair IgE of 3. In addition, the provider notes the patient has positive allergy testing. The patient’s pulmonary function tests showed an FEV1 of 71% and a post-test FEV1 of 82% showing reversibility. In May 2004, the patient was taking Advair 500/50, Singulair, and Combivent inhaler. She was also taking Zyrtec D, Diflucan QD, Tamoxifen, Prednisone, and Albuterol nebulizer. The submitted notes indicate the patient was experiencing exacerbations and urgent unscheduled visits to her physician.

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