Myasthenia Gravis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for 112 hours per week (16 hours per day) of nursing services. Myasthenia gravis causes weakness in the skeletal muscles. This condition may affect breathing, chewing and movement of extremities. Individuals with this condition may experience weakness and fatigue at the end of the day or after prolonged activity. This fatigue can lead to increased risk of complications, including aspiration of secretions and poor airway management. Patients with this condition often require close supervision and frequent tracheal suctioning.

Findings: The physician reviewer found that The patient has requested authorization and coverage for Ruxience (rituximab-pvvr) infusions (700 mg infused weekly for 4 doses). Gilhus and Verschuuren describe myasthenia gravis as an autoimmune disease that is B-cell mediated, and is associated with antibodies directed against the acetylcholine receptor, muscle-specific kinase (MUSK), lipoprotein-related protein 4 (LRP4), or agrin in the postsynaptic membrane at the neuromuscular junction. Standard pharmacotherapy including acetylcholine esterase inhibitors, corticosteroids, and nonsteroidal immunosuppressive agents, including azathioprine, mycophenolate mofetil, methotrexate, cyclosporine, and tacrolimus, and are usually effective in the treatment of myasthenia gravis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Neural Zoomer Plus test. Findings: The physician reviewer found that Neural Zoomer Plus is an array of neurological autoantibodies offering specific antibody-to-antigen recognition, designed to assess an individual’s reactivity to 48 neurological antigens, which may be connected to a variety of neurologically related diseases. Markers measured include demyelinating agents, blood brain barrier disruption, optical and autonomic nervous system disorders, peripheral neuropathy, neuromuscular disorders, brain autoimmunity, brain inflammation, and infections. The following antibodies are tested for neuromuscular disorders: anti-acetylcholine receptors, anti-muscle specific kinase, anti-voltage gated calcium channels, anti-voltage gated potassium channels, and anti-titin.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hospice care services. The records provided for review suggest that this patient is at an elevated risk of mortality. However, the patient’s condition lacks the markers of expected mortality within the next six months to support an indication for the requested hospice care services. There are challenges to predicting six-month mortality in Alzheimer’s patients. One key factor is nutrition and hydration. The patient is maintaining her nutrition and hydration as she is eating 50-75% of her meals. In addition, the patient does not have pressure wounds, aspiration pneumonia, kidney failure, or other major co-morbidities associated with six-month mortality in patients with advanced dementia. The patient’s diagnosis of myasthenia gravis is not a determining factor in her need for hospice care.

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