Lupus Nephritis: when insurers say no, reviewers often say yes
In 13 published external-review decisions involving lupus nephritis, independent physician reviewers overturned the insurer’s denial 92.3% of the time.
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.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lupkynis 7.9 mg. The records document that this patient presents with a history of chronic kidney disease and proteinuria secondary to lupus nephritis. The provider reports that the patient’s condition has been stable with a regimen consisting of Plaquenil, CellCept, and voclosporin (Lupkynis). The provider has recommended continued treatment with this regimen. Per the American College of Rheumatology (ACR) guidelines, continuing Lupkynis is appropriate for this patient. As noted in the medical literature, there are data demonstrating the efficacy of Lupkynis in the treatment of patients with active lupus nephritis.
Where the denial was upheld
The patient is a 30-year-old female who has been diagnosed with chronic kidney disease as a result of lupus nephritis and anemia. The patient’s provider diagnosed the patient based on proteinuria over 2 grams. The patient is now anemic. The patient’s provider has recommended Procrit for treatment of the patient’s anemia. The Health Plan has denied authorization for the requested medication stating the patient does not meet Health Plan criteria for its use.The use of Procrit to treat the anemia of chronic renal failure is best documented to be successful when the glomerular filtration rate is low. Review of the relevant medical literature reveals the glomerular filtration rate is typically below 30, though sometimes anemia can improve with Procrit for glomerular filtration rates between 30 and 60.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 lupus nephritis was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY