End Stage Renal Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dialysis after 5:00 pm. Findings: The physician reviewer found that there are potential complications that can occur during and immediately following dialysis including low blood pressure, fatigue, and prolonged bleeding, which can interfere with a patient’s ability to perform activities of daily living. In addition, many patients experience other symptoms following dialysis. As noted in the medical literature, noncompliance with dialysis has been associated with a poorer clinical outcome. A medical study dependably demonstrates substantially inferior health-related outcomes associated with missing treatments in hemodialysis patients. Moreover, mechanical difficulties with the dialysis machine itself are not infrequent, and can delay the time for dialysis to be completed.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Privigen x 2 (split dose over two days) 50 grams each day and Actemra 680 mg every four weeks. Based on the available documentation, this patient presents with biopsy proven B cell-mediated rejection status post kidney transplant in 2016 due to end-stage renal disease. Treatment has included intravenous immunoglobulin (IVIG), Actemra, tacrolimus, and belatacept. Given the ongoing concern for rejection, her provider has recommended an additional course of IVIG followed by monthly Actemra for six doses. Per Choi and colleagues, significant reducing donor specific antibodies (DSAs) has been demonstrated to improve long-term outcomes in patients with antibody-mediated rejection.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for FreeStyle Libre blood glucose 14-day reader device and FreeStyle Libre sensors. According to the medical literature, FreeStyle Libre flash glucose monitor obtained approval to function as an alternative for self-monitoring, such as finger-stick glucose monitoring. The factory-calibrated disk-like sensor is worn on the upper arm for 14 days and promotes the ease of taking multiple glucose readings per day. An enrollee may do so by passing a reader device over the sensor and obtain real-time glucose levels and trends.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nonemergency medical transportation (NEMT) gurney transportation to and from dialysis.At issue is whether nonemergency medical transportation (NEMT) gurney transportation to and from dialysis is medically necessary. Gurney (litter) vans are transportation vehicles that can accommodate a gurney for patients who are unable to sit upright for the duration of the journey. In this case, the patient is deconditioned and has a prior history that includes stroke, atrial fibrillation, hypertension, congestive heart failure and diabetes mellitus. The patient has been hospitalized in the previous months for post-dialysis complications and possible stroke. The submitted documentation includes a home health evaluation following the patient’s most recent hospitalization.

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 end stage renal disease, then check the rights and deadlines that apply to your plan.