Eosinophilic Esophagitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for increasing the dosage of the medication, budesonide. Muir and Falk describe eosinophilic esophagitis as an immune-mediated chronic esophageal disorder that is diagnosed using both clinical and pathologic information. Patients commonly have high rates of concurrent allergic diseases, especially food sensitization, compared with the general population. Standard therapies for eosinophilic esophagitis include dietary modification, acid suppression using PPIs, topical fluticasone, topical budesonide, and dilatation for esophageal stricture. Swallowed topical-acting corticosteroids are effective in bringing active eosinophilic esophagitis into remission. The U.S. Food and Drug Administration (FDA) designates budesonide as an orphan drug for the treatment of eosinophilic esophagitis.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Neocate Junior formula (chocolate flavor). The Health Plan has denied this request indicating that the requested formula is not medically necessary for treatment of the enrollee who has a history of allergies to certain food.The submitted documentation supports the medical necessity for the requested oral formula. Dietary elimination is recognized as an established treatment for eosinophilic esophagitis. A four-food elimination diet with avoidance of milk, wheat, egg, and soy, can induce remission in 64% of subjects as reported in a recent publication. However, even more stringent restrictions are not effective in all patients. Furthermore, dietary elimination alone has not been able to maintain appropriate growth in this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for oral nutritional supplement, Neocate Junior. Findings: The physician reviewer found that the submitted documentation does not support the medical necessity for requested nutritional supplement in this clinical setting. EoE is an atopic disorder leading to inflammation of the esophagus and associated symptoms of dysphagia, nausea, and abdominal pain with associated poor weight gain. Although there is some support in the medical literature that an elemental diet can be an effective management of EoE, more focused elimination diets lead to remission in up to 45 percent of cases. In this patient’s case, the documentation indicates that his dysphagia and esophageal eosinophilia have resolved with avoidance of peanut, soy, and wheat.

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for leukocyte histamine release test (CPT 86343) for evaluation of the enrollee who has a history of asthma and eosinophilic esophagitis. Findings: The physician reviewers found that there is a lack of support for the superior efficacy of the services at issue in this clinical setting. This patient has a history of asthma, allergic rhinitis, dermatographism and EoE. In this patient’s case, there is no diagnosis of chronic uncontrolled urticaria, only dermatographism which is a physical urticaria. Laboratory evaluation has failed to confirm an autoimmune process. The services at issue is a leukocyte histamine release assay. At this time, the clinical utility of this test is not well established and there are currently no national allergy and immunology or dermatology guidelines recommending routine use of this test.

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