Anti-Fungal denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jublia 10% topical solution. Findings: The physician reviewer found that Onychomycosis is a fungal infection of the nail which can result in pain, disfigurement, and secondary infection. Ulcerations of the nail bed as well as resultant osteomyelitis of the underlying phalanges may result, particularly in patients with peripheral neuropathy. Onychomycosis can be caused by dermatophytes, yeasts or nondermatophyte molds. The most common dermatophyte organisms that cause onychomycosis are Trichophyton rubrum and Trichophyton mentagrophytes. Diagnosis is made by patient history, physical findings, and diagnostic testing. Onychomycosis can be treated by oral and topical antifungals. Oral medications have systemic risks and so are not appropriate for all patients.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for Cayston. The records indicate that this patient has a longstanding history of chronic and acute-on-chronic airway infections that have required treatment with inhaled antibiotics. Initially, parenteral formulations of antibiotics such as tobramycin were nebulized, particularly for patients colonized with Pseudomonas aeruginosa. Over time, formulations of antibiotics have been created specifically for inhalation. The largest group of patients for whom this therapy is recommended are those with cystic fibrosis. Patients with cystic fibrosis have a severe inability to clear airway secretions and are prime targets for Pseudomonas colonization.

Where the denial was upheld

The patient is a 41-year-old male with chronic eye pain and chronic rhinosinusitis. The records provided include multiple notes from several physicians with different specialties. He has had problems with chronic bilateral eye pain (also referred to variously as retro-orbital pain and atypical facial pain) for many years. He has had several surgeries, received neuro-ganglion blocks, and takes oral analgesics on a regular basis for this problem. There are detailed notes related to possible adverse affects experienced by the patient with the use of Neurontin and gabapentin. There are two physician dictations regarding this patient’s sinus disease history. In October 2004 it is noted that the patient had a history of nasal and paranasal sinus polyposis.

Findings: The physician reviewer found that An enrollee has requested authorization and coverage for itraconazole 100 mg capsules. There is a paucity of standard treatment recommendations for the management of patients with dermatophytosis. Diagnosis is made clinically, although culture is considered the gold standard to confirm diagnosis and identify the species involved. The records document that this patient underwent a biopsy, which revealed dermatophytosis from the left upper flank. At that time, the provider recommended treatment with a course of oral terbinafine. The chart notes indicated that a rash was still present, although no culture or KOH preparation was made. At that time, the provider recommended treatment with itraconazole.

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 Anti-Fungalwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.