Common Variable Immunodeficiency denials in California external review

What the reviewers wrote

Where the denial was overturned

An enrollee has requested authorization and coverage for subcutaneous immune globulin (SCIG). Common variable immunodeficiency is a disorder with impaired immunity, including B cell differentiation with hypogammaglobulinemia with varying degrees of loss of antibody. Typically, there are recurrent infections, chronic lung disease, gastrointestinal disease and autoimmune disorders. Treatment often includes immune globulin replacement. Although treatment with intravenous immune globulin may be necessary for those with substantial impairments in immune globulin production and no response to both protein and polysaccharide vaccines, for patients with higher levels of serum IgG and only minor impairments in response to some vaccines, intravenous immune globulin treatment can be deferred.In this patient’s case, testing revealed an inadequate response to the Pneumovax vaccine.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for immunoglobulin therapy, Cuvitru. Per the medical records, the patient’s circulating B-cells and B-cell subsets by flow cytometry demonstrate very low switched memory B-cells, a finding that, when combined with the patient’s clinical history and other immunologic studies, is consistent with common variable immunodeficiency (CVID). The patient has a chronic history of frequent respiratory infections, confirmed with positive cultures with Haemophilus influenzae type B, which have led to bronchiectasis and two sinus surgeries. The patient’s total immunoglobulin levels have been normal. The records noted an initial response to pneumococcal vaccination, though the patient’s protective titers have decreased over time.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy and epidural steroid injection. Findings: The physician reviewer found that there is a lack of supporting documentation such as chest x-rays, chest computed topography, sinus computed topography, pharmacy antibiotic records or antibiotic log to confirm this diagnosis. A single set of laboratory results show a low total IgG, but there is no repeat of laboratory work up to confirm. Moreover, there is a lack of evaluations for other signs of protein loss, and there is no specific antibody titers of pre- and post- vaccination titers. The records provided do not clearly evaluate the patient’s ability to respond to infections or lack thereof as required for the diagnosis of common variable immunodeficiency (CVID).

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIG immunoglobulin replacement therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee’s hypogammaglobulinemia and common variable immunodeficiency (CVID).At issue in this case is whether the requested IVIG immunoglobulin replacement therapy is medically necessary for treatment of the patient’s medical condition.In this case, the patient has evidence of hypogammaglobulinemia. Although stated there have been recurrent infections, per the practice parameters there is no supporting documentation: (chest x-ray (CXR); computed tomography (CT) chest; CT sinus; pharmacy antibiotic records; or antibiotic log) to confirm this.

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 common variable immunodeficiency, then check the rights and deadlines that apply to your plan.