Systemic Lupus Erythematosus 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 Gammagard intravenous immune globulin infusions (35 grams infused every four weeks for six months). Hypogammaglobulinemia may occur in persons with systemic lupus erythematosus (SLE) and is a potential risk factor for infection. Researchers note that SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Management of hypogammaglobulinemia in persons with SLE should be individualized and tailored to a patient’s individual risk of infection.

enrollee has requested authorization and coverage for Infini laser treatments. Infini radiofrequency microneedling laser system delivers controlled radiofrequency energy to break down scars to deep skin layers. This bipolar radiofrequency system generates fractional zones of electrothermal damage deep in the dermis, surrounded by areas of undamaged tissue under a more-or-less intact epidermis. These areas of damage in the dermal matrix induced a vigorous wound healing process supported by the surrounding undamaged tissue and lead to the synthesis of new collagen and elastin, dermal remodeling and replenishment of hyaluronic acid. Microneedle fractional radiofrequency also showed improvement of acne scars and large facial pores with less adverse events than fractional lasers. In a study, 20 patients were treated with Infini lasers for atrophic, burn, photoaging and acne scars.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) red light therapy machine for home use, (2) ultrasound machine for home use, and (3) cold therapy unit for home use. There is limited evidence in current medical literature supporting the use of red-light therapy, also referred to as low-level laser therapy (LLLT). Childress and Beutler report regarding the management of chronic tendon injuries, “Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.” However, Baktir and colleagues report regarding the short-term effectiveness of LLLT, “LLLT p…

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication, HP Acthar Gel, 80 units twice a week. The enrollee has seronegative rheumatoid arthritis and systemic lupus erythematosus. The enrollee began treatment with prednisone and Plaquenil. Methotrexate and Enbrel were added, with partial benefit. The enrollee has trialed Humira, Cimzia and Actemra without benefit. Methotrexate was discontinued due to gastrointestinal upset. The enrollee was started on Simponi Aria intravenous infusions. She continues to take Plaquenil with significant control of her disease. Her rheumatologist is requesting HP Acthar Gel, 80 units/mL, to treat the enrollee’s systemic lupus erythematosus.

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 systemic lupus erythematosus, then check the rights and deadlines that apply to your plan.