Antibiotics denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: This patient is a 43-year-old female who underwent renal transplant in 1992 due to focal segmental glomerulosclerosis (FSGS). She is on now on dialysis and requires a second renal transplant. A live donor is available; however the patient is highly sensitized and had a positive crossmatch with the potential donor. The patient’s transplant specialist recommends desensitization with IVIG and Rituxan prior to transplant, and indicates that plasmapheresis may also be required. The provider’s request for authorization of the desensitization protocols was denied by the Health Plan citing the experimental nature of the therapies.The proposed therapies are considered to be the standard of care and are not investigational.

The enrollee is a 53-year-old female who has a 4.5-year history of chronic sinusitis with recurrent acute infection. Additionally she has problems with migraine headaches and has been diagnosed with fibromyalgia. An additional compounding factor in this patient’s care is her stated history of multiple antibiotic allergy. Initial treatment in November 2000 included oral antibiotics and nasal saline irrigation. A CT scan in December 2000 showed “near complete filling of the maxillary sinuses” with osteomeatal complex obstruction, minimal patchy disease of the ethmoids, clear sphenoids, and undeveloped frontal sinuses. After failure of initial therapy the patient underwent bilateral FESS as well as septoplasty. The surgeon notes the findings of “thick fungal” material at surgery.

Where the denial was upheld

Physician 1The patient is a 34-year-old female first diagnosed with Lyme disease in 2001. She subsequently received multiple courses of antibiotic with minimal long-term results. She had one six-month course of antibiotic with minimal change in her condition. She reports experiencing fatigue, paresthesia, arthralgias, fever, photophobia and headaches. These symptoms have persisted for several years. The patient feels the symptoms are increasing in severity. Physical exam findings include peripheral neuropathy with no effusions or erosion of large joints. Laboratory data include a positive IgG Western blot, normal brain MRI, and abnormal nerve conduction studies. No CSF analysis has been provided. A request has been made for continued intravenous antibiotic therapy.

Physician 1: The patient is a 65-year-old man who is said to have a history of Lyme disease. There is no evidence in the provided materials that the patient actually had this disease. The results of the definitive serological tests (Western Blots) included in the records are not conclusive. No other laboratory data of consequence is provided. There is a CD57 count that is slightly low and a non-specific SPECT brain scan performed in 2003; these are not diagnostic of Lyme disease.There is no mention in the submitted information of tick exposure or the characteristic rash seen in early Lyme disease. The medical records provided are from the patient’s primary care physician. The records note the patient is being treated with intravenous Rocephin and a quinolone antibiotic. He was given intravenous Rocephin for 10.5 months.

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 Antibiotics, then check the rights and deadlines that apply to your plan.