Pulmonary Fibrosis: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan (rituximab 1000 mg every two weeks). Sharp and colleagues explain that connective tissue disease-associated interstitial lung disease often fails to respond to conventional immunomodulatory agents. In examining the results of 24 patients with interstitial lung disease patients treated with rituximab after failing to improve with standard therapy, the authors reported that lung imaging remained stable or improved for 11 patients, while worsening was observed in nine patients. The authors found that decline in forced vital capacity (FVC) improved following rituximab treatment, while diffusion capacity of carbon monoxide was stable. The authors concluded that rituximab is a therapeutic option in treatment-refractory connective tissue disease-associated interstitial lung disease.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with idiopathic pulmonary fibrosis (IPF). The patient had a chest CT scan that found interval extensive progression of pulmonary fibrosis, with increased extensive honeycombing in the bilateral lower lobes, left greater than right, especially in the sub-pleural left lower lobes medially and right lower lobe. The CT scan also revealed an increase in honeycombing in the left upper lobe anteromedially, and to a lesser extent to the anteromedial sub-pleural right upper lobe. The patient was seen for evaluation of idiopathic pulmonary fibrosis. The patient had mild symptoms of coughing with breathlessness. Ultimately, the patient was noted as having dry inspiratory crackles on the physical exam. A chest x-ray was noted to be consistent with reticular opacities.

Where the denial was upheld

The patient is a 59-year-old male with idiopathic pulmonary fibrosis (IPF). According to an initial consultation with his pulmonologist, the patient has a medical history of diabetes mellitus, coronary artery disease, and is status post coronary artery bypass graft. At this consultation, the patient presented with progressive shortness of breath, non-productive cough and abnormal chest radiograph. The patient was previously hospitalized twice for pneumonia. Spirometry showed FVC 71%, FEV1 82%, and FEV1/FVC 92%. On 2/4/04, a CT scan of the chest revealed bilateral interstitial fibrosis primarily at the bases and periphery. Results of bronchial washings and transbronchial biopsy performed on 2/13/04 were non-diagnostic. On 3/1/04, an open lung biopsy revealed unusual interstitial pneumonitis.

The enrollee is requesting authorization and coverage for vest airway clearance system. The enrollee has a history of pulmonary fibrosis, bronchiectasis, and chronic obstructive pulmonary disease. He requires chest physical therapy to clear secretions and currently does not have a caregiver to perform it. The enrollee’s advocate reports consistent, aggressive airway clearance is necessary for the enrollee to maintain his pulmonary function. Retention of secretions can lead to chronic inflammation and progressive lung damage, with the possibility of developing resistance to standard treatment. Medical records did not demonstrate this enrollee had a continuous, productive cough for more than six months. Records do not demonstrate that this enrollee experienced frequent exacerbations, more than two, in the last year which required treatment with anti-infective medications.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for pulmonary fibrosis was denied, the published record says the denial is worth fighting.