Eczema 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 authorization and coverage for exome sequencing testing (CPT 81415). The provider caring for this patient has recommended whole exome sequencing (WES) for diagnostic purposes given the constellation of symptoms including enamel hypoplasia, eczema, vitiligo, xerosis, and skin hypopigmentation. In contrast to current sequencing tests that analyze one gene or small groups of related genes, WES will analyze the exons or coding regions of over 20,000 genes. Therefore, sequencing the exome is an effective method of analyzing the patient’s DNA to discover the genetic cause of diseases or disabilities.

A 45-year-old female enrollee has requested a home phototherapy (UVB) unit for treatment of her dermatitis. Findings: The physician reviewer found that dermatitis is histologically diagnosed based on specific findings. The histology is useful to exclude other diagnoses, but requires clinical correlation to establish a more specific diagnosis of eczema. Acute eczema is characterized by spongiosis, a mainly intercellular edema between the epidermal keratinocytes leading to micro or macro vesicles (Boguniewicz and Leung). Treatment of chronic eczema usually starts with topical agents, such as corticosteroids as well as phototherapy, including broad-band UVA (UVB-BB), UVA with psoralen, and UVA-1. More recently, narrow-band UVB has emerged as an effective treatment modality (Majoie, et al). This patient’s skin disease is consistent with the diagnosis of chronic eczema.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for sublingual immunotherapy and/or food tolerance induction. This patient presents with food allergies and eczema. His parent has requested treatment in a tolerance induction program. Currently, the American Academy of Allergy Asthma and Immunology (AAAAI) does not recommend tolerance induction as a standard of care treatment for patients with food allergies due to the uncertainty whether the potential therapeutic benefits outweigh the risks of treatment (Nowak-Wegrzyn, et al.; Gernez and Nowak-Wegrzyn). Although some studies have reported positive outcomes, according to the AAAAI, the interventions and endpoints used in clinical trials have been too inconsistent to establish oral immunotherapy as superior to allergen avoidance.

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Eucrisa 2% ointment for treatment of the enrollee’s eczema. Findings: The physician reviewer found that the Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient’s eczema. The submitted documentation does not support the medical necessity of the requested medication. Eucrisa is an inhibitor of phosphodiesterase 4, a novel non-steroidal treatment for children over the age of two years. It can be applied to any part of the body. without concern for side effects. It is intended for treatment of mild to moderate eczema.

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