Adult Immunization denials: what the review data shows

Where the denial was overturned

An enrollee has requested authorization and coverage for the Gardasil 9 vaccine series. Updated recommendations of the CDC Advisory Committee on Immunization Practices (ACIP) for vaccination against human papillomavirus (HPV) note that the public health benefit of HPV vaccination in all adults greater than 26 years of age is minimal, but that shared clinical decision-making regarding HPV vaccination is recommended for some adults aged 27 to 45 years, because some persons who are not adequately vaccinated might benefit. In this case, the patient is within the 27 through 45 years age range identified by the ACIP. Furthermore, the updated recommendations of the ACIP state that shared decision-making regarding HPV vaccination is recommended for this population.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gardasil human papillomavirus (HPV) three-dose schedule vaccine. Findings: The patient presents with a history of abnormal pap smear and she is at continued risk of cervical cancer. The Gardasil HPV vaccine series is U.S. Food and Drug Administration (FDA) approved for patients ages 9 through 45 years of age for prevention of cervical cancer caused by multiple HPV types. Per a study, vaccination against HPV is “recommended to prevent new HPV infections and HPV-associated diseases, including some cancers.” This patient may not have been exposed to all the different HPV types thus far, therefore vaccination is still considered protective. Given this support, the requested Gardasil HPV three-dose schedule vaccine is medically necessary for treatment of this patient.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for a respiratory syncytial virus (RSV) vaccine (Beyfortus). The current Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommendation for Beyfortus is for administration to infants less than eight months of age born during or entering their first RSV season and for infants and young children from eight months to 19 months at increased risk for severe RSV disease entering their second RSV season. Additional groups recommended to receive Beyfortus when entering their second RSV season include children with severe immunocompromise and children with cystic fibrosis with either severe lung disease or weight-for-length less than the 10th percentile.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a shingles vaccine for treatment of his medical condition. Findings: The physician reviewer found that the submitted medical records fail to demonstrate that the patient requires the shingles vaccine. In a study by Oxman et al, they enrolled 38,546 adults 60 years of age or older in a randomized, double-blind, placebo-controlled trial of an investigational live attenuated Oka/Merck VZV vaccine (zoster vaccine). The authors found that the zoster vaccine markedly reduced morbidity from herpes zoster and post-herpetic neuralgia among older adults.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Adult Immunizationwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.