Multiple Sclerosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 54-year-old female with multiple sclerosis (MS) diagnosed 12 years ago. There has been significant progression of the disease over the past eighteen months and she was diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP). The patient experienced severe right-sided weakness and a course of IVIG did not improve her symptoms. She underwent five days of plasmapheresis and regained strength in her lower extremities. The patient now requests reimbursement for the plasmapheresis. The Health Plan considers the therapy experimental/investigational and has denied coverage.In patients with MS and CIDP, the latter condition is usually treated with IVIG as a first step. If the patient does not respond beneficially, as was the case with this patient, plasmapheresis is the next step and is frequently effective.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for glatiramer acetate. The McDonald criteria are used for diagnosing multiple sclerosis (MS) in patients who have a typical clinically isolated syndrome suggesting the onset of relapsing-remitting MS. The McDonald criteria define an MS attack as a single-phase clinical episode with patient-reported symptoms and objective findings typical of MS, reflecting a focal or multifocal inflammatory demyelinating event in the central nervous system. Development can be acute or sub-acute, with a duration of at least 24 hours, with or without recovery, and in the absence of fever or infection. The most common initial attacks are sensory disturbances, motor weakness, and visual complaints.

Where the denial was upheld

Findings: The physician reviewer found that The patient is a 51-year-old individual with a history of multiple sclerosis. The patient is reported to have been initially diagnosed with multiple sclerosis in 2003 (relapsing-remitting type). Subsequently The patient acquired a COVID-19 infection. The patient is reported to have been hospitalized for approximately one month and experienced paralysis, muscle loss, and weight loss. Records from The patient primary care provider indicated that the patient had diarrhea, right-sided weakness, and multiple syncopal episodes (most likely due to hypovolemia) during hospitalization. The patient was discharged back to the community with a hospital-grade manual wheelchair which was difficult and painful to self-propel due to its weight and configuration.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a motor scooter.The 25-foot walk test has been recognized as an ideal measure for objective characterization of walking dysfunction for persons with multiple sclerosis. In a recent, large quantitative synthesis review, mean 25-foot walk test scores were reported of 4.3±0.8 seconds for controls without multiple sclerosis (MS), 6.7±3.1 seconds for ambulatory persons with MS overall, 5.2±1.1 seconds for persons with mild MS, and 10.6±8.3 seconds for persons with moderate to severe MS. Slower gait speeds on this test have been associated functionally with clinically meaningful outcomes such as greater incapacity status and higher frequency of falls.

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