Autoimmune Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested reimbursement and prospective authorization and coverage for intravenous immunoglobulin (IVIG) infusions (Gammagard 86 grams divided over three days every four weeks) provided, and prospective authorization and coverage for IVIG infusions (Gammagard 86 grams divided over three days every four weeks). Pediatric acute-onset neuropsychiatric syndrome (PANS) is defined by the sudden onset of obsessive compulsive disorder (OCD) or eating restrictions and comorbid symptoms. Acute onset cases that are triggered by Group A streptococcal infections may meet diagnostic criteria for both PANS and pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). These two syndromes display highly similar symptoms and guidelines often treat them as a single entity (Thienemann, et al.).

Nature of Statutory Criteria/Case Summary: The patient is a 13-year-old female with a diagnosis of irritable bowel syndrome-constipation subtype. She also has a history of dysautonomia and vasovagal syncope, dizziness, and postural orthostatic tachycardia syndrome. The medical records note the patient has struggled with constipation since she was six months of age and has been treated with MiraLAX since that time. An esophagogastroduodenoscopy (EGD) and colonoscopy in showed focal active ileitis with a single ill-defined granuloma. A magnetic resonance elastography (MRE) in was noted to be normal. The patient was treated with budesonide for a couple months, but symptoms persisted/worsened. Despite MiraLAX, one cap daily, the patient was noted to have bowel movements from twice daily to (more commonly) once weekly. She also takes senna as needed. Imaging showed moderate constipation.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel.Findings: The physician reviewer found that American College of Rheumatology guideline on the treatment of psoriatic arthritis notes, “In treatment-naive patients with active psoriatic arthritis (PsA), a tumor necrosis factor inhibitor (TNFi) biologic agent is recommended over an oral small molecule (OSM) as a first-line option. OSMs may be used instead of a TNFi biologic in patients without severe PsA and without severe psoriasis, those who prefer an oral drug instead of parenteral therapy, or those with contraindications to TNFi treatment, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing services [F5 (coagulation factor V) (e.g. hereditary hypercoagulability) gene analysis, Leiden variant; F2 (prothrombin, coagulation factor II) (e.g. hereditary hypercoagulability) gene analysis, 20210G>A variant; and MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g. hereditary hypercoagulability) gene analysis, common variants (e.g. 677T, 1298C)]. There is a lack of evidence to support the use of the services at issue for the diagnosis or management of hypothyroidism or low testosterone. Genetic testing is not part of the diagnosis or treatment of hypothyroidism or low testosterone.

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