Polyneuropathy denials in California external review

What the reviewers wrote

Where the denial was overturned

A 45-year-old female enrollee has requested for Lyrica for the stated diagnosis of polyneuropathy for treatment of her medical condition. Findings: The physician reviewer found that this patient’s records demonstrate that she has failed treatment with numerous medications. In addition, she has undergone radiofrequency neuromodulation of the sympathetic chain. The patient reports that a trial of Lyrica provided her relief from her neuropathic pain. Although use of Lyrica in the treatment of peripheral neuropathy would be an off-label use of the medication, this patient has tried other treatments without success and she has had a positive response on a trial of the drug. Although officially approved only for diabetic neuropathy, post herpetic neuralgia, and fibromyalgia, many medications are used off-label with successful outcomes.

A 52-year-old male enrollee has requested Lyrica for the treatment of his polyneuropathy. Findings: Two physician reviewers found that Lyrica has been beneficial for this patient. Lyrica is medically appropriate for the treatment of painful diabetic neuropathy. Management of neuropathic pain is usually a clinical extension of what is learned in clinical trials with well-studied neuropathy pain, typically diabetic in origin. There is no evidence that non-diabetic neuropathy pain responds differently than pain from diabetic neuropathy. There is evidence that supports the use of Lyrica in cases with non-diabetic neuropathic pain, including postherpetic neuralgia and fibromyalgia. Lyrica should be approved for this patient. He has already failed gabapentin, and he has had successful response to Lyrica.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Beeks arch support shoes and a Simmons 6th generation bed including Super Plush Pillow Topper.Researchers state that excessive foot pronation during gait is a risk factor in medial tibial stress syndrome (MTSS). Researchers studied the effects of bilateral foot orthoses during running on dynamic foot-pressure distribution patterns in recreational runners with MTSS and found that arch-support foot-orthoses may help with conditions such as MTSS. Hsieh and colleagues conducted a randomized controlled trial to examine the short-term effects of customized arch support insoles on symptomatic flexible flatfoot in children.

The patient is a 66-year-old male and has neuropathic symptoms of painful foot and leg tingling. Spinal stenosis has been diagnosed. Lumbar laminectomy has been performed in the past. The patient’s HbA1C was normal, but fasting glucose was elevated. No glucose tolerance test results are cited. A podiatry evaluation for plantar fasciitis resulted in a diagnosis of neuropathic symptoms “apparently from the back.” NSAIDs, Neurontin, physical therapy, and spinal injections were tried without sustained relief. Recently, the patient received a trial of Lyrica. The patient and his provider indicate Lyrica has completely controlled his symptoms. At issue is whether Lyrica is medically necessary for treatment of the patient’s medical condition.The patient has symptoms suggesting polyneuropathy. Etiologic diagnosis is unclear.

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