Parkinson's Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement and prospective authorization and coverage for long-term custodial care services.Admission to a skilled nursing facility (SNF) for skilled nursing services is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician as well as constantly available skilled nursing services. Patients require skilled nursing services, including wound management, tracheostomy care, bowel and bladder training, tube feeding, and administration of intravenous (IV) medications or medications that cannot be self-administered safely. Patients at the SNF level of care also require skilled nursing observation, including regular monitoring of vital signs, skin in the setting of wounds, and intake and output.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rytary 23.75-95 three capsules, three times a day and/or Neupro patch one time nightly. Levodopa is recommended for the first-line treatment of patients with Parkinson’s disease (Spindler, et al.). The combination drug carbidopa-levodopa is an immediate-release formulation (immediate-release [IR] Sinemet). In addition, two longer-acting oral levodopa formulations exist: an older, controlled-release tablet and a newer, extended-release capsule (Liang, et al.). The extended-release capsule formulation of carbidopa-levodopa (Rytary) has been shown to be helpful for patients experiencing motor fluctuations with standard tablet forms of levodopa despite dose adjustments and use of adjunctive dopaminergic medications.

Where the denial was upheld

Physician 1: The patient is a 49-year-old woman with nearly a two-year history of progressive slowing and rigidity of the right arm. She is seeking a fluro-dopa PET scan for definitive diagnosis of Parkinson’s disease. The submitted records indicate the patient has shown a response to Sinemet and a movement disorder specialist has diagnosed probable Parkinson’s disease. The Health Plan has denied coverage for the requested PET scan on the basis PET scanning has not been shown to be efficacious for evaluation of the patient’s condition.PET scanning is an investigational tool in the management of Parkinson’s disease. There has been no proven long-term benefit of PET in the treatment of Parkinsonian disorders. While use of PET may confirm a definitive diagnosis of Parkinson’s disease, it will not change the patient’s therapy, which at this time is not disease modifying.

Nature of Statutory Criteria/Case Summary: The patient is a 56-year-old female with Parkinson’s disease (PD). The patient was diagnosed with PD. She was started on carbidopa/levodopa (Sinemet) 25/100mg three times a day. Per a letter from her provider, she was unable to tolerate a full dose of the drug due to side effects. She then tried one-half tablet three times per day, but this was not effective for symptom control. She was then started on a treatment course of one-half tablet every three hours. Per the provider, this dosing schedule was only partially effective. The record indicated that while the patient had an improvement on Sinemet IR, there was also noted to be a degree of fluctuation in her symptomatic control. The patient was started on a trial of Rytary ER. The patient has subsequently reported improvement in control of her motor symptoms.

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 parkinson's disease, then check the rights and deadlines that apply to your plan.