Relapsing Remitting Multiple Sclerosis: 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 Kesimpta. The American Academy of Neurology (AAN) practice guideline recommendations for disease-modifying therapies (DMTs) for adults with multiple sclerosis note that as numerous studies of DMTs in patients with relapsing forms of multiple sclerosis who have had recent relapses or magnetic resonance imaging (MRI) activity, or both, have shown a benefit with DMT in terms of reducing relapses and reducing MRI activity, clinicians should offer DMTs to patients with relapsing forms of multiple sclerosis with recent clinical relapses or MRI activity. The guidelines further note that when a patient shows breakthrough disease activity, such as continued relapses and/or MRI activity, trying a medication with a different mechanism or efficacy profile may be beneficial.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with relapsing-remitting multiple sclerosis. The records noted that recent magnetic resonance imaging (MRI) demonstrated multiple subcortical and periventricular white matter lesions and a single tiny enhancing lesion in the right cerebellar white matter, radiologically suspicious for multiple sclerosis. The MRI was initially done because of symptoms of hearing loss and intermittent tinnitus. The provider noted that a lumbar puncture confirmed findings consistent with multiple sclerosis with 12 oligoclonal bands in the cerebrospinal fluid. The patient reported right hand/forearm numbness and tingling that began two to three years prior. The provider noted that the patient was John Cunningham (JC) virus antibody negative.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for power wheelchair accessories including sit to stand features. This patient presents with relapsing remitting multiple sclerosis. Per the provider, the patient’s condition has progressed, and she is unstable for transfers. The provider has recommended a power wheelchair with elevation seat system and power stander to enable her to safely perform activities of daily living and improve bilateral lower extremity swelling. There is a lack of evidence demonstrating that use of a power stander feature equipped on a power wheelchair provides clinically significant benefits with respect to health or functional outcomes in the setting of neurological weakness due to multiple sclerosis or other conditions impairing the active ability to stand.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavenclad. At issue is whether the requested Mavenclad is medically necessary for the treatment of this patient. According to guideline recommendations, multiple studies have shown the benefit of disease-modifying therapy (DMT) in terms of reducing relapses and magnetic resonance imaging (MRI) activity in patients with relapsing forms of multiple sclerosis who have had recent relapses and/or MRI activity. The guidelines state that providers should offer DMT to patients with relapsing forms of multiple sclerosis with recent clinical relapses or MRI activity. The U.S.

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 relapsing remitting multiple sclerosis was denied, the published record says the denial is worth fighting.