Arthritis Rx denials: what the review data shows

Where the denial was overturned

Physician 1The patient is a 65-year-old woman who has been diagnosed with Gaucher’s disease type I. The patient has been receiving enzyme replacement therapy for several years. She underwent a left knee replacement one year ago for unknown reasons with some residual tenderness noted three months later. The submitted notes indicate there was a small area of avascular necrosis at the superior aspect of the right femoral head seen on an MRI performed in May 2003. This was presumably a stage I lesion since it was not seen on x-ray. X-rays of the spine, hips, and knees show only minimal disc and degenerative joint changes without fractures, lytic lesions or deformities such as the Erlenmeyer flask deformity classic for Gaucher’s disease. DEXA scans of the spine and hip for bone mineral density reveal normal T scores compared to young adult women and no evidence of osteoporosis.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the requested medication, Orencia injections. The enrollee has rheumatoid arthritis, seropositive and centromere antibody positive. She started Humira and at a follow-up visit reported continued pain and loss of motion in a right finger. She also reported resolution of right wrist pain and knee pain. Her prior treatments include prednisone, which was tapered; methotrexate, for which higher doses were believed to be associated with hair loss; Humira, which she is no longer taking, and Enbrel. The enrollee’s rheumatologist requested prior authorization for Orencia, but in the interim, changed the enrollee’s medication to Enbrel. At a follow-up visit, improvement in foot pain was noted, but no significant change in her hand/finger symptoms.

Where the denial was upheld

The patient is a 62-year-old female with rheumatoid arthritis (RA) of indeterminate duration who was described by her rheumatologist in June 2004 as having continuing active disease with synovitis despite ongoing treatment with methotrexate 25mg/wk, Plaquenil 200mg twice a day, and Celebrex 200mg twice a day. The patient is said to have ongoing morning stiffness and fatigue and is unable to participate in all of her activities of daily living.The patient’s primary complaint at the time of her visit seemed to be ongoing difficulty with shoulder pain and difficulty using her arms. Her history includes prior bilateral synovectomies of her shoulders. An exam described markedly restricted range of motion in both shoulders with improved swelling in her left thumb and right ring finger, and without full extension in the right elbow.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s medical condition.Findings: Nationally recognized evidence based medical guidelines state that hyaluronic acid injections (Orthovisc) in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities.

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