Small Fiber Neuropathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Privigen intravenous immunoglobulin (IVIG) in-home infusion. The standard of care treatment for patients with small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain. Many medications have also been tried in the treatment of painful polyneuropathy with varying success including duloxetine, pregabalin, carbamazepine, phenytoin, topiramate, baclofen, mexiletine, and dextromethorphan. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to relieve the pain. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard intravenous immunoglobulin infusions (35 grams daily for three days, then 52 grams for one to two days every three to four weeks for one year). Finnerup and colleagues report that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Liu and colleagues explain that small fiber polyneuropathy may have various underlying causes, including associations with systemic autoimmune conditions, and that intravenous immunoglobulin is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Octagam 50 gm intravenous (IV) daily for four days x one course, then 50 gm IV daily for two days every four weeks x 16 weeks. Small fiber neuropathy (SFN) occurs as a result of injury to the small unmyelinated C-fibers or thinly myelinated nerve fibers, causing symptoms of numbness, sensory loss, electric shock-like pain, cold-like pain, itching, burning, tingling, and a feeling of pins and needles. In this case, the patient has a diagnosis of SFN, likely due to an inflammatory cause. The patient reports symptoms including burning in her feet, stiffness in her legs and hips, progressive muscle weakness, tingling and numbness in the hands and feet, and spasms of the lower limbs.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammagard infusions 60 grams every four weeks. This patient’s records document small fiber neuropathy, which the provider noted is likely due to Sjogren’s. The provider has recommended treatment with Gammagard infusions. There is a lack of prospective randomized controlled clinical studies demonstrating the long-term safety and efficacy of intravenous immunoglobulin (IVIG) for the treatment of patients with small fiber neuropathy. Gaillet and colleagues reported data suggesting that IVIG treatment can be effective and well-tolerated in patients with small fiber neuropathy. However, the authors concluded that their findings “have to be confirmed in a randomized double-blinded placebo-controlled trial.” IVIG has been approved by the U.S.

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 small fiber neuropathy, then check the rights and deadlines that apply to your plan.