Infectious Disease: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC services provided. ASAM criteria focus on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral, and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient had no signs or symptoms of withdrawal after detoxification was completed.

Physician 1: The patient is a 52-year-old male with HIV related lipodystrophy. He is requesting coverage for Serostim injections to alleviate symptoms and side effects relative to fat accumulation including respiratory distress, limited range of motion, and need to modify sitting/sleep position. Prior interventions including diet, exercise, metformin and testosterone provided no benefit. The Health Plan indicates Serostim injections are considered investigational for treatment of lipodystrophy. Given the well-documented morbidity associated with the patient’s abdominal lipodystrophy, a trial of therapy with Serostim is indicated. It does not appear there is an alternative intervention for this patient with a severe condition that continues to worsen despite multiple interventions.

Where the denial was upheld

Physician 1The patient is a 34-year-old female first diagnosed with Lyme disease in 2001. She subsequently received multiple courses of antibiotic with minimal long-term results. She had one six-month course of antibiotic with minimal change in her condition. She reports experiencing fatigue, paresthesia, arthralgias, fever, photophobia and headaches. These symptoms have persisted for several years. The patient feels the symptoms are increasing in severity. Physical exam findings include peripheral neuropathy with no effusions or erosion of large joints. Laboratory data include a positive IgG Western blot, normal brain MRI, and abnormal nerve conduction studies. No CSF analysis has been provided. A request has been made for continued intravenous antibiotic therapy.

Physician 1: The patient is a 65-year-old man who is said to have a history of Lyme disease. There is no evidence in the provided materials that the patient actually had this disease. The results of the definitive serological tests (Western Blots) included in the records are not conclusive. No other laboratory data of consequence is provided. There is a CD57 count that is slightly low and a non-specific SPECT brain scan performed in 2003; these are not diagnostic of Lyme disease.There is no mention in the submitted information of tick exposure or the characteristic rash seen in early Lyme disease. The medical records provided are from the patient’s primary care physician. The records note the patient is being treated with intravenous Rocephin and a quinolone antibiotic. He was given intravenous Rocephin for 10.5 months.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for infectious disease was denied, the published record says the denial is worth fighting.