Interferon denials in California external review

What the reviewers wrote

Where the denial was overturned

This patient is a 43-year-old female with chronic active hepatitis C, genotype 1a who was treated with PEG Intron and ribavirin in 2004, and relapsed after the completion of therapy. She has no history of suicide or depression. The patient’s last liver panel revealed normal bilirubin, AST, ALT, total protein, albumin, total bilirubin, PT and INR. The HCV-PCR in December 2005 was 21,099,000 Iu/ml. Her liver ultrasound revealed mild hepatic steatosis without focal lesions. When last evaluated by her hepatologist, the patient was doing well and showed no signs or symptoms of decompensated liver disease. She had no symptoms of mental confusion or forgetfulness. The patient has requested authorization for retreatment with Infergen and ribavirin therapy.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Actimmune (interferon). Coccidioidal meningitis is a life-threatening fungal infection of the central nervous system. In this case, the patient has been diagnosed with coccidioidal meningitis and she is requesting treatment with Actimmune. She previously received treatment with a ventriculoperitoneal (VP) shunt and has tried and failed numerous medications. The patient is now being treated with fosmanogepix and trialing posaconazole again. Coccidioidal meningitis is a difficult-to-treat invasive infection. The medical literature reports evidence that Actimmune has been shown to slow disease progression with a beneficial response in the treatment of coccidioidal meningitis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Plegridy Pen for treatment of the enrollee’s relapsing multiple sclerosis. Findings: The physician reviewer found that this patient has longstanding multiple sclerosis with mild disability and recent increase in disease activity. She discontinued one disease modifying therapy six years previously due to interferon side effects. It has now been recommended she use Plegridy, which is a pegylated interferon, every two weeks. As this is an interferon that is nearly identical to Rebif, it would be expected that the patient would have similar side effects. It has been the experience of many providers that Plegridy actually has more interferon related side effects than all of the other interferons.

The patient is a 57-year-old man with a history of hepatitis C. The patient was given Peg-Intron and Rebetol for at least five months. Review of the submitted records indicates the patient did not clear his virus and there was only a 1.4 log drop in his viral count. A repeat course of Peg-Intron and Rebetol therapy has been recommended by the patient’s provider. The Health Plan indicates that a second course of Peg-Intron and Rebetol therapy is not medically indicated given the patient’s insufficient response to the initial course of therapy.It is not the standard of care to retreat patients who have not responded to an initial course of Peg-Intron and Rebetol therapy. The article by Fried, et al.

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