Rheumatoid Arthritis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the requested medication, Orencia injections. The enrollee has rheumatoid arthritis, seropositive and centromere antibody positive. She started Humira and at a follow-up visit reported continued pain and loss of motion in a right finger. She also reported resolution of right wrist pain and knee pain. Her prior treatments include prednisone, which was tapered; methotrexate, for which higher doses were believed to be associated with hair loss; Humira, which she is no longer taking, and Enbrel. The enrollee’s rheumatologist requested prior authorization for Orencia, but in the interim, changed the enrollee’s medication to Enbrel. At a follow-up visit, improvement in foot pain was noted, but no significant change in her hand/finger symptoms.

Nature of Statutory Criteria/Case Summary: The patient is a 24-year-old female diagnosed with moderately to severely active seropositive (RF+/CCP+) rheumatoid arthritis. She was previously treated with methotrexate which failed to control her rheumatoid arthritis. The patient was noted to have a needle phobia. Due to the needle phobia the patient was not started on injectable or intravenous tumor necrosis factor (TNF) inhibitor therapy for rheumatoid arthritis. The patient was subsequently placed on Rinvoq 15mg daily with significant improvement in her joint pain, joint swelling and joint stiffness. On 11/21/2022, the patient reported improvement in bilateral foot, hand, knee, ankle, wrist and shoulder pain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Hydrocodone-Acetaminophen (Norco) 10-325mg tablets, quantity of 120 tablets per month, taken as one (1) tablet by mouth every 6 hours as needed.Standard therapy for rheumatoid arthritis/psoriatic arthritis includes the use of biologic drugs and DMARDs which are immunosuppressive therapies and carry the risk for infection. Due to a history of the left knee prosthetic joint infection, the patient has chosen to avoid biologic drugs and other DMARDs and is currently on hydrocodone-acetaminophen, which is an opiate, a controlled substance, to control chronic joint pain.Opioid pain medication use presents serious risks, including overdose and opioid use disorder.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s rheumatoid arthritis, complex regional pain syndrome type 2 right leg, and chronic pain syndrome. A review of the record indicates that the enrollee has been diagnosed with chronic pain syndrome, peripheral neuropathy, rheumatoid arthritis (RA), and complex regional pain syndrome (CRPS) type 2 right leg. The records indicated the enrollee has been taking Norco in the past. Medical records indicated the enrollee presented for medication management and has had rheumatoid arthritis. The enrollee reported tingling in the bottoms of the feet and hands and reported pain medications help their neuropathy.

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