Resp Allergies denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 50-year-old male with a history of chronic sinusitis. He had maxillary advancement surgery in 1982. There is a questioned history of Caldwell-Luc sinus surgery in 1990. In 1992, the patient underwent right-sided functional endoscopic sinus surgery. In 2000, he continued with chronic sinusitis symptoms. Medical therapy has included allergy shots, multiple nasal steroid sprays, Atrovent, Astelin, Singulair, multiple oral antihistamines, oral steroids, Kenalog injections, in addition to multiple antibiotics. The patient subsequently underwent revisional functional endoscopic sinus surgery, septoplasty, and turbinate reduction surgery. Despite multiple surgical interventions and aggressive medical therapy he still continues to experience episodes of sinusitis. He was treated with a course of Rocephin in 2002.

The patient is a 57-year-old male with moderate to severe allergic asthma and chronic sinusitis, with seasonal and year-round allergies. He has tried various medications but has been unresponsive to standard medical treatments. His lung function tests revealed a low FEV1.The patient underwent skin testing in 1997 with positive results to trees, grasses and weeds. His IgE level was reported as 39.1 IU/ml in May 1997. The patient’s current medications include Advair, Singulair, Flonase, Nexium, Zyrtec, Optivar, and Duratuss. He has also received a variety of other medications, including inhaled corticosteroids, theophylline and long-acting beta-agonists. Review of progress notes indicate the patient was taking 20mg prednisone in April 2002, indicating severe steroid dependency.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested reimbursement for allergy tests (immunoassay for allergy or toxicity and IgG food test). The patient’s provider recommended evaluation with testing as part of the treatment protocol within the tolerance induction program (TIP). The TIP is a form of oral immunotherapy (OIT), which is still in the early stages of development and still requires further investigations to optimize protocols and improve safety. The potential therapeutic benefits of OIT must be carefully considered in light of the significant potential for adverse events, including oropharyngeal, respiratory, or gastrointestinal symptoms.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested Cromolyn Sodium for the treatment of postural orthostatic tachycardia syndrome (POTS) and newly diagnosed mast cell activation syndrome (MCAS).Based on the clinical documentation for review, the requested cromolyn sodium is not medically necessary for the treatment of the patient’s POTS or MACS conditions. A study indicated that the symptoms associated with MCAS can be managed by blockade of mediator receptors with H1 and H2 antihistamines or leukotriene receptor blockade, inhibition of mediator synthesis with aspirin or zileuton, mediator release with cromolyn sodium, anti-immunoglobulin therapy, or a combination of these approaches. The provider letter dated 04/11/23 does indicate a diagnosis of MACS and that the patient utilizes cromolyn sodium.

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