Small Fiber Polyneuropathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIg Gammagard liquid 10% (37 grams every 2 weeks). Hovaguimian and Gibbons note that management of small-fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain. Finnerup and colleagues report that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Liu and colleagues report evidence suggesting that intravenous immunoglobulin (IVIg) is safe and effective as a first-line treatment for patients with small-fiber-targeting autoimmune diseases akin to Guillain-Barré and chronic inflammatory demyelinating polyneuropathy.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous Panzyga [140 grams over five consecutive days (20 gm/30 gm/30 gm/30 gm/30 gm) followed by 60 grams over two consecutive days (30 gm/30 gm) monthly for six cycles]. Hovaguimian and Gibbons note that management of small-fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain, which can include several different classes of medications. Colleagues report that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gamunex-C. Small fiber polyneuropathy occurs because of injury to the small unmyelinated C or thinly myelinated nerve fibers, and causes symptoms of numbness, sensory loss, electric shock-like pain, cold-like pain, itching, burning, tingling, and pins and needles feeling. The first line treatment for small fiber neuropathy includes tricyclic antidepressants (TCAs) such as amitriptyline, nortriptyline, and clomipramine, serotonin and norepinephrine reuptake inhibitors (SNRIs), and anticonvulsants such as duloxetine, gabapentin, and pregabalin. In this case, the patient was diagnosed with a small fiber neuropathy secondary to inflammatory or post-infection, with symptoms of tingling and burning pain in her extremities, sensitivity to cold temperature, and difficulty ambulating.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG) (10%/120 grams, every four weeks). Liu and colleagues note that small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions, while Morrison and Chaudhry note that a large number of medications and toxins may also produce neuropathy. Geerts and colleagues note that in the first double-blind, randomized, controlled trial evaluating the efficacy and safety of intravenous IVIG versus placebo in patients with idiopathic small fiber neuropathy, IVIG treatment had no significant effect on pain in patients with painful idiopathic small fiber 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 small fiber polyneuropathy, then check the rights and deadlines that apply to your plan.