Resp Infection: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for inpatient neonatal intensive care unit (NICU) services. There are well-defined criteria for the safe discharge of neonatal patients. This patient had been stressed in utero, as evidenced by the meconium-stained fluid and thick meconium in her mouth and nose, the need for emergent cesarean section, depressed state at delivery, respiratory distress, and need for non-invasive ventilatory support, and chest radiographic findings.

A 23-year-old female enrollee has requested reimbursement for urgent care services. Findings: The physician reviewer found that the patient presented for urgent care due to a history of productive cough, headache, runny nose, scratchy throat and phlegm for four days. She complained of having felt feverish. Her brother was also ill for a period of time. The patient’s symptoms were unresponsive to over the counter medications. Her vital signs were normal. A letter from the patient and her parent indicated that the patient’s primary care physician did not have an appointment available for several weeks. Physical examination on the date in question was significant for erythema of the pharynx. The patient was diagnosed with an acute respiratory infection and was discharged on antibiotics and an antitussive medication.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the Synagis vaccine. At issue in this case is whether the requested Synagis vaccine is medically necessary for treatment of the enrollee’s medical condition. In 2014, the American Academy of Pediatrics issued new guidelines for the administration of Synagis for respiratory syncytial virus (RSV) prophylaxis based on review of current peer-reviewed literature related to burden of RSV in infants and children with emphasis on those at highest risk of severe disease.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) with Gammagard 45 grams intravenous (IV) every three weeks. Findings: The physician reviewer found that patients with IgG subclass deficiency require more extensive diagnostic evaluation including the demonstration of a poor antibody response to vaccine challenge to support a diagnosis of a clinically significant IgG subclass deficiency. Subclass deficiencies need to be carefully interpreted taking into account the clinical status of the patient as well as the patient’s ability to produce specific antibodies in response to vaccines.

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 resp infection was denied, the published record says the denial is worth fighting.