Chron Kidney Failure ESRD 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 with a diagnosis of primary membranous nephropathy has requested authorization and coverage for rituximab 10 mg infusion with a quantity of 100 units. The records document that this patient presents with a history of stage 4 chronic kidney disease. The patient’s provider has recommended continued treatment with rituximab. As noted in the current medical literature, rituximab is considered the standard of care therapy for patients with membranous nephropathy. Chronic kidney disease is a chronic condition and in the absence of appropriate treatment, this patient is at high risk of progression. The provider reported that this patient is receiving treatment with rituximab, which is a well-supported therapy for membranous nephropathy and consistent with current medical literature recommendations.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Soliris (eculizumab) intravenous infusions.C3 glomerulopathy is an ultra-rare disorder with an incidence of approximately one per million per year. The current treatment recommendations state to treat with mycophenolate mofetil (MMF) and glucocorticoids for at least six months. The recommendations indicate that the patient should be weaned from the glucocorticoids but continue the MMF. However, if the patient has an adequate response, the patient is to be weaned off the glucocorticoids but continue the MMF. If there is an inadequate response to both the MMF and glucocorticoids, the provider is directed to discontinue the therapy and switch to Soliris (eculizumab).

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a cystatin C with eGFR (estimated glomerular filtration rate) lab test. Cystatin C is an endogenous biomarker used to estimate glomerular filtration rate (GFR) and may serve as an adjunct to serum creatinine testing in specific clinical situations. Evidence suggests that cystatin C-based eGFR may improve accuracy in patients with extremes of body composition, muscle wasting, or other factors affecting creatinine production. However, its routine use in the general population remains limited due to variability in assay calibration and a lack of conclusive data showing superior outcomes compared with creatinine-based eGFR estimation.

Findings: The physician reviewer found that a patient has requested authorization and coverage for oocyte cryopreservation, including reproductive endocrinology visits; ovarian stimulation medications (gonadotropins), gonadotropin-releasing hormone (GnRH) antagonist/agonist, ovulation trigger [human chorionic gonadotropin (hCG) or GnRH-analogue]; monitoring labs and ultrasounds; transvaginal oocyte retrieval with anesthesia; embryology services (oocyte identification vitrification/cryopreservation); initial storage (12 months); related laboratory fees and infection screening. There is a lack of scientific data showing that certain medications cause iatrogenic infertility and that other medications affects fertility in men or women without diabetes. Per the medical records, the patient has diagnoses of immunoglobulin A (IgA) nephropathy and chronic kidney disease.

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 chron kidney failure esrd, then check the rights and deadlines that apply to your plan.