Chronic Inflammatory Demyelinating Polyneuropathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 54-year-old female with multiple sclerosis (MS) diagnosed 12 years ago. There has been significant progression of the disease over the past eighteen months and she was diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP). The patient experienced severe right-sided weakness and a course of IVIG did not improve her symptoms. She underwent five days of plasmapheresis and regained strength in her lower extremities. The patient now requests reimbursement for the plasmapheresis. The Health Plan considers the therapy experimental/investigational and has denied coverage.In patients with MS and CIDP, the latter condition is usually treated with IVIG as a first step. If the patient does not respond beneficially, as was the case with this patient, plasmapheresis is the next step and is frequently effective.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy, Gammagard liquid, infused every four weeks at home. CIDP is an autoimmune disorder that causes progressive weakness, sensory deficits, and impaired nerve conduction due to immune-mediated demyelination. Without treatment, it can lead to significant disability, highlighting the importance of timely intervention with evidence-based therapies. First-line treatments include IVIG, subcutaneous immunoglobulin, corticosteroids, and plasma exchange. Gammagard Liquid is an FDA-approved IVIG therapy proven to treat neuromuscular disability and impairment in adults with CIDP. A review of medical studies has supported its effectiveness.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Privigen (intravenous immune globulin (IVIG) for treatment of the enrollee’s chronic inflammatory demyelinating polyneuropathy (CIDP). Findings: The physician reviewer found that although IVIG is standard treatment of CIDP, the documentation submitted for review does not support the diagnosis in this case. In general, the following criteria support the diagnosis of CIDP: progression over at least two months, weakness more than sensory symptoms, symmetric involvement of arms and legs, proximal muscles involved along with distal muscles, reduced deep tendon reflexes throughout, increased cerebrospinal fluid protein without pleocytosis, nerve conduction evidence of a demyelinating neuropathy and nerve biopsy evidence of segmental demyelination with or without inflammation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested an intravenous immunoglobulin (IVIG) infusion for treatment of her medical condition. Findings: The physician reviewer found that this patient’s records lack findings to support a diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP). Specifically, there are no significant clinical findings to support this diagnosis. The patient’s electromyography (EMG) was interpreted as normal and an EMG study alone is inadequate to evaluate for CIDP. The standard work-up includes a spinal fluid analysis looking for elevated protein. Further, the records do not demonstrate a paraneoplastic etiology since the patient has no evidence of cancer as her lesions were biopsied and proven to be benign.

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 chronic inflammatory demyelinating polyneuropathy, then check the rights and deadlines that apply to your plan.