Food Allergies denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for allergy testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of food allergies.Findings: There is support for the services at issue in this clinical setting. The use of food specific IgG is utilized in the setting of oral immunotherapy (OIT) administration to monitor tolerance. According to current management guidelines for chronic urticaria, chronic autoimmune urticaria can be differentiated from idiopathic urticaria by the presence of auto-antibodies to IgE receptors. Patients with a chronic urticaria and who have a positive functional test result for autoantibody to the immunoglobulin E (IgE) receptor, will likely have an autoimmune basis for the diagnosis.

The parent of a 1-year, 11-month-old female enrollee has requested for Alimentum ready to feed (RTF) formula for treatment of the enrollee’s food allergies. Findings: The physician reviewer found that symptoms such as abdominal pain, constipation, and regurgitation are relatively common in children. In the medical literature, Heine found that, “Gastroesophageal reflux disease, constipation and colic are among the most common disorders in infancy and early childhood. In at least a subset of infants with these functional disorders, improvement after dietary elimination of specific food proteins has been demonstrated.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested reimbursement and prospective authorization and coverage for proprietary Tolerance Induction Program™ services, including ingestion challenge testing, allergy testing, and office visits. The patient’s provider recommended treatment with a tolerance induction program to help address enrollee food allergies. Currently, the American Academy of Allergy Asthma and Immunology (AAAAI) does not recommend oral immunotherapy as a standard treatment for patients with food allergies due to uncertainty whether the potential therapeutic benefits outweigh the risks of treatment.

Findings: The physician reviewer found that The parent of an enrollee has requested authorization and coverage for blood tests.This patient presented to the provider with a history of food allergies. The provider has recommended a large range of laboratory testing as part of the ongoing oral immunotherapy (OIT). However, there is a lack of support for this panel, which has not been demonstrated to provide benefit in the evaluation and treatment of patients with food allergies. According to the American Academy of Allergy, Asthma and Immunology (AAAAI) practice parameter for food allergies, the use of the requested blood tests as diagnostic or prognostic indicators of food allergy is controversial. According to AAAAI, some of the requested tests are used to evaluate immunodeficiency disorders and are not widely used for evaluation for food allergy.

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