Lupus 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: An enrollee has requested authorization and coverage for Gammagard intravenous immune globulin infusions (35 grams infused every four weeks for six months). Hypogammaglobulinemia may occur in persons with systemic lupus erythematosus (SLE) and is a potential risk factor for infection. Researchers note that SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Management of hypogammaglobulinemia in persons with SLE should be individualized and tailored to a patient’s individual risk of infection.

The enrollee is requesting authorization and coverage for home wax bath kit/portable paraffin bath unit. The enrollee has a past medical history of herniated intervertebral disc, status post discectomy, and was seen for joint pain that had been ongoing. The enrollee initially noticed the pain in her right middle finger at the distal interphalangeal (DIP) joints and thought it was due to trauma. The pain initially subsided, but it never went away and eventually progressed to her right wrist, as well, which felt very tender. She also felt tenderness at times in her left hand/wrist. Her physician ordered an x-ray, which was negative. Laboratory test results indicated antinuclear antibody (ANA) was positive, C-reactive protein (CRP) level was nine and erythrocyte sedimentation rate (ESR) was within normal limits. She was diagnosed with lupus and was further evaluated by a rheumatologist.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) red light therapy machine for home use, (2) ultrasound machine for home use, and (3) cold therapy unit for home use. There is limited evidence in current medical literature supporting the use of red-light therapy, also referred to as low-level laser therapy (LLLT). Childress and Beutler report regarding the management of chronic tendon injuries, “Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.” However, Baktir and colleagues report regarding the short-term effectiveness of LLLT, “LLLT p…

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab (Rituxan) for treatment of her lupus. Findings: The physician reviewer found that There is a lack of support in the documentation provided and in the medical literature for the requested medication in this clinical setting. This case involves a patient with active neuropsychiatric SLE. A review by researchers looked at the EXPLORER trial for depleting B cells in patients with moderate to severely active extra-renal SLE. Their study did not demonstrate a difference between placebo and rituximab in the primary and secondary end points. They noted the following, “A beneficial effect of rituximab on the primary end point was observed in the African American and Hispanic subgroups.

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