Neuropathy denials in California external review

What the reviewers wrote

Where the denial was overturned

A 53-year-old male enrollee has requested Cymbalta 30mg capsule (duloxetine HCL) twice per day for treatment of his neuropathy and radiculopathy. Findings: The physician reviewer found that based on review of the available records, duloxetine (Cymbalta) is medically necessary for the patient’s medical condition. The patient has tried and failed to benefit from standard therapies. Additionally, the patient’s medical condition is both chronic and seriously debilitating. Cymbalta is supported in the peer-reviewed medical literature as a safe and effective treatment for combined disorders of chronic joint pain, neuropathy and depression. Raskin and colleagues performed a multi-center double blind randomized controlled trial to assess the efficacy and safety of Cymbalta on the reduction of pain severity in patients with diabetic peripheral neuropathy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for orthotics for treatment of the enrollee’s foot pain. Findings: The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of orthotics. In this case, the patient has collapsed arch, pain upon ambulation, neuropathy, a significant hypermobility syndrome and Ehlers-Danlos syndrome. Custom orthotics have been demonstrated to be effective in the treatment of the above mentioned pathologies. Custom orthotics are firm functional devices that support both the medial arch as well as the midtarsal arch, and will reduce hypermobility, support the foot and slow if not halt further progression of patient’s foot deformity. Reducing hypermobility in the foot will likely help alleviate the patient’s foot pain.

Where the denial was upheld

Physician 1: This case involves a 45-year-old male who presents with left-sided numbness of his upper and lower extremities and to a lesser extent numbness of his face. He has a past medical history of possible sarcoidosis, monoclonal gammopathy, hyperlipidemia, hypertension, diabetes, attention deficit hyperactivity disorder (ADHD), bladder stones, and transitional cell cancer of the bladder. On physical examination, sensation was mildly decreased to light touch across the left side of his face. His sensation to vibration was also decreased on the left side of the face.The submitted records indicate the patient has had two MR studies of his brain. In December, 2004, an MRI of the brain and MRI spectroscopy of the brain were performed. This report refers to a prior MR study of the brain from January 2004.

Physician 1The patient has neuropathy possibly from a B12 deficiency. The patient’s reported symptoms include bilateral foot coldness and pain and sleep disturbance. The patient also has a non-healing ulcer at the dorsum of the left foot. The patient’s provider recommended Anodyne therapy, which the patient has undergone with reported benefit. She has requested authorization and coverage for home Anodyne therapy. The Health Plan has denied her request indicating that Anodyne therapy is considered investigational.The Health Plan’s denial should be upheld. Though the patient has been diagnosed with neuropathy, there is no evidence that the patient’s diagnosis has been further qualified. In any event, Anodyne therapy is of unclear benefit. The efficacy of Anodyne therapy has not been established through significant, case-controlled studies.

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