Immunoglobulin A Nephropathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Filspari tablet. Immunoglobulin A nephropathy (IgAN) is a leading cause of chronic kidney disease (CKD) and progression to end-stage kidney disease (ESKD). The primary goal of therapy is to prevent progression to ESKD. IgAN treatment is risk-stratified based on proteinuria levels, kidney function, and presence of hematuria. In patients with persistent proteinuria greater than 0.5 grams per day despite more than three months of optimal angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker and sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy, CKD stage 3 with impaired renal reserve, and the absence of other modifiable contributors to proteinuria, the medical literature supports the use of Filspari.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Tarpeyo. In this case, the record establishes that the patient has biopsy-proven immunoglobulin A nephropathy (IgAN), significant proteinuria with a urine protein-to-creatinine ratio (UPCR) and progressive kidney disease. This patient's UPCR of 1,279 mg/g substantially exceeds the threshold proteinuria greater than or equal to 0.5 g/day warranting a recommendation for Tarpeyo. Additionally, the patient is currently on other medications, which address downstream consequences of nephron loss through reduction of glomerular hyperfiltration and proteinuria. However, these medications do not target the underlying pathogenic IgA production that drives IgAN progression.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for HP Acthar Gel 40 units, 2 times per week for 4 weeks, then titrate to 80 units, 2 times per week for 5 months. The enrollee has stage 4 chronic kidney disease. At an office visit, her provider indicated the amount of interstitial fibrosis and tubular atrophy was working against her success rate. The provider’s recommendation was for the enrollee to continue angiotensin II receptor blockers The pharmacist reports the enrollee’s condition has worsened; despite maximum evidence-based, non-immunosuppressive therapy. She is spilling a high level of protein in her urine; at a rate of 7.3 grams per day. Normal urinary protein is less than 150 milligrams per day.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Filspari. The primary goal of treatment of immunoglobulin (Ig) A nephropathy is to prevent disease progression to end-stage kidney disease. This goal is primarily achieved through nonimmunosuppressive strategies and supportive care. The target is a urine protein-to-creatinine ratio (UPCR) of less than 1 g/day, and if possible, less than 0.5 g/day. This target may be achieved by blood pressure control, use of maximally tolerated renin–angiotensin–aldosterone system (RAAS) blockades, treatment of dyslipidemia, and lifestyle modifications. If, after three months of optimized supportive care, the patient remains at high risk for progression of disease, other agents may be added.

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 immunoglobulin a nephropathy, then check the rights and deadlines that apply to your plan.