Iron Deficiency Anemia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for Ferrlecit infusions to be given every 30 days for a minimum of six months. Kaneva and colleagues report that intravenous iron is an alternative for children with severe iron deficiency anemia who have difficulty in adhering to or absorbing oral iron. The authors further note that the use of intravenous iron sucrose in pediatric patients with severe iron deficiency anemia is safe and leads to a moderate increase in hemoglobin and substantial improvement in iron studies. The records note that the patient presented to the emergency room with iron deficiency anemia leading to a syncopal episode.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for iron sucrose injections for treatment of the enrollee’s low ferritin levels. Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The medical literature indicates that approximately 70% of patients experience gastrointestinal side effects to oral iron. Intravenous (IV) iron is considered a standard of care for many patients, especially those that cannot tolerate oral iron.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for a home hemoglobin testing device. The gold standard for monitoring hemoglobin and other blood indices is with lab testing using venous blood. More recently, with the advent of smartphones, applications have been designed to facilitate monitoring, particularly in areas where resources for lab draws and laboratory testing are scarce. In this case, the patient has been diagnosed with iron deficiency anemia and has been treated with iron supplementation in the form of oral medications and patches. The patient has blood draws as needed to follow-up supplementation. Due to the ease of use and ability to track and compare without invasive testing, these devices are often considered preferred by patients, but they are not considered the standard of care.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for capsule endoscopy. In this case, the patient has had iron-deficiency anemia, and an upper endoscopy and colonoscopy were unrevealing. The American Gastroenterological Association (AGA) guidelines for the gastrointestinal evaluation of iron-deficiency anemia notes that in uncomplicated asymptomatic patients with iron deficiency anemia and negative bidirectional endoscopy, the AGA suggests a trial of initial iron supplementation over the routine use of video capsule endoscopy. Researchers report, “Positive findings on video capsule endoscopy led to subsequent endoscopic interventions only in a small percentage of patients with iron deficiency anemia. Anemia improved and resolved equally whether there were video capsule endoscopy findings.

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 iron deficiency anemia, then check the rights and deadlines that apply to your plan.