Chron Kidney Fail: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1: This patient is a 43-year-old female who underwent renal transplant in 1992 due to focal segmental glomerulosclerosis (FSGS). She is on now on dialysis and requires a second renal transplant. A live donor is available; however the patient is highly sensitized and had a positive crossmatch with the potential donor. The patient’s transplant specialist recommends desensitization with IVIG and Rituxan prior to transplant, and indicates that plasmapheresis may also be required. The provider’s request for authorization of the desensitization protocols was denied by the Health Plan citing the experimental nature of the therapies.The proposed therapies are considered to be the standard of care and are not investigational.

Nature of Statutory Criteria/Case Summary: An enrollee has requested air and associated ground ambulance transportation services for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that air and associated ground ambulance transportation services are medically necessary for treatment of the patient’s medical condition. Based on the documentation submitted for review, a work-up for renal transplantation has been approved at an out of state transplant facility. The patient does not have the option of going to another transplant center. The kidney transplant process takes a great deal of time with referral, wait, appointments, work-up, and approval. The process of getting listed at another center and approved could take up to two years.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intradialytic parenteral nutrition (IDPN) therapy. Findings: The physician reviewer found that the requested service is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. There is a lack of published data demonstrating meaningful clinical outcomes are improved with IDPN therapy. A two-year multicenter, prospective, randomized study demonstrated that IDPN provided to malnourished patients on dialysis did not improve patient outcomes. A study performed a prospective controlled study involving 113 dialysis patients receiving IDPN. The study demonstrated an improvement in albumin but no significant improvement in subjective local nutritional assessment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tocilizumab (Actemra) injections. Chronic antibody mediated rejection (ABMR) is the most common cause of graft failure and is more difficult to treat than acute AMBR, since tissue damage has occurred to the renal allograft. Chronic ABMR is also more common in patients who develop de novo donor specific antibodies (DSA) following kidney transplant. In terms of treatment, there is a lack of published randomized controlled clinical trials evaluating the efficacy of the various available therapeutic options for ABMR. Djamali and colleagues reported on a case series of patients treated with Actemra and noted that “significant reductions in DSA and stabilization of renal allograft function were observed at two years”.

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 chron kidney fail was denied, the published record says the denial is worth fighting.