Anti-histamines denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent enrollee has requested authorization and coverage for two, four pack boxes of epinephrine 0.15 mg/0.15 mL injectable autoinjector, not from a lot containing particulate matter. The first-line of treatment for patients experiencing anaphylaxis is epinephrine. Studies of anaphylaxis have identified important risk factors. Based on a national registry, several risk factors for anaphylaxis from foods have been identified. As anaphylactic episodes might require more than one dose of epinephrine, all patients should carry two packs of epinephrine auto-injectors. This patient has experienced prior severe allergic reactions and remains at high risk for anaphylaxis.

Nature of Statutory Criteria/Case Summary: An enrollee who has requested authorization and coverage for EpiPen two pack for treatment of the enrollee, who has allergies to nuts. Findings: The physician reviewer found that the medical evidence show that epinephrine administration is a critical component of individualized emergency action plans for patients at risk for anaphylaxis. The auto injector should be portable, identifiable, safe, and effective. In this patient’s case, the history and laboratory data indicate that the patient had a significantly elevated IgE level to multiple food items. Her laboratory testing showed a class 4 reaction to walnuts, and a class 3 reaction to soybean, wheat, sesame seeds, hazelnuts and almonds. She had multiple positive results to respiratory allergens such as pollen, dust mites, and animal dander.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for allergy injections. Allergy shots may be indicated for persistent symptoms on a seasonal and/or perennial basis for patients with an inadequate or partial response to environmental control and medications. In this case, the medical records do not demonstrate a failure to respond to the new medication regimen, cetirizine and Flonase. The records do not establish that allergen immunotherapy is warranted at this time. As noted by colleagues, “the immunotherapy build-up schedule (also called updosing, induction, or the dose-increase phase) entails administration of gradually increasing doses during a period of approximately.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a ProAir HFA albuterol inhaler for treatment of her medical condition. Findings: The physician reviewer found that the requested medication has not been established as medically necessary for treatment of the patient’s medical condition. The management of asthma per the Global Initiative for Asthma (GINA) guidelines divide asthmatics by their degree of control and based on that determine what step of treatment they require. All five steps have as their foundation the use of short acting beta agonists (albuterol) to achieve immediate relief during an acute worsening of asthma symptoms. The efficacy of short acting beta agonists for the management of acute asthma is long proven. In this case, the patient is requesting ProAir, an ethanol containing preparation.

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