Guillain-barré Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

An enrollee has requested reimbursement for air ambulance services provided. Findings: The physician reviewer found that the air ambulance services provided was medically necessary for treatment of the patient’s medical condition. GBS is an acute progressive sensory-motor polyneuropathy. It is an autoimmune condition which if untreated can progress to respiratory failure, and can be fatal. It is standard of care for an acute GBS patient to have access to neurology and critical care expertise. IVIG is standard of care for GBS. In this case, air ambulance services from Arcata to Sacramento is estimated to be less than two hours. In addition, the hospital is an estimated 3-4 hours by ground transport lists two neurologists within a 10 mile radius.

The spouse of a 59-year-old male enrollee has requested transfer to a facility with a higher level of care for the treatment of the enrollee’s multiple medical conditions including Guillain-Barre Syndrome. Findings: The physician reviewer found that this patient has had a severe paralytic illness, consistent with Guillain Barre Syndrome (GBS). The prolonged nature of his symptoms, along with observed atrophy, suggests axonal involvement as is seen in the acute axonal variant of GBS. CIDP is a chronic form of demyelinative neuropathy, reaching a nadir in more than eight weeks. IVIG can be beneficial for GBS, but does not always result in improvement. Plasmapheresis has been shown beneficial for GBS when given early in the illness. As with other inflammatory neuropathies, CIDP is treated with immunosuppressants with variable levels of evidence for the efficacy of each.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for SNF services. Admission to a SNF is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician along with constantly available skilled nursing services. Skilled nursing services may include wound management, tracheostomy care, bowel and bladder training, tube feeding, and the administration of intravenous (IV) medications or medications that cannot be self-administered safely. Skilled nursing observation may include regular monitoring of vital signs, skin in the setting of wounds, and intake and output. Patients typically also benefit from skilled therapy services such as physical, occupational, and speech therapies due to physical limitations, a decline in function, or impaired cognition and communication.

Nature of Statutory Criteria/Case Summary: A 56-year-old male enrollee has requested reimbursement for long-term acute care inpatient stay for treatment of Guillain-Barre syndrome and West Nile virus. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Guillain-Barre syndrome generally has a favorable natural course and relatively good prognosis. There are treatment options such as intravenous immunoglobulin and plasma exchange that have demonstrated to be effective treatments for this condition. However, despite the generally good prognosis and available therapeutic options, some patients continue to have significant functional impairments at six months or longer following the onset of symptoms.

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 guillain-barré syndrome, then check the rights and deadlines that apply to your plan.