Kesimpta denials in California external review
In the California DMHC record, independent physician reviewers decided 33 published external-review cases involving Kesimptaand overturned the plan’s denial in 100%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Multiple Sclerosis | 23 | 100% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Kesimpta. The American Academy of Neurology (AAN) practice guideline recommendations for disease-modifying therapies (DMTs) for adults with multiple sclerosis note that as numerous studies of DMTs in patients with relapsing forms of multiple sclerosis who have had recent relapses or magnetic resonance imaging (MRI) activity, or both, have shown a benefit with DMT in terms of reducing relapses and reducing MRI activity, clinicians should offer DMTs to patients with relapsing forms of multiple sclerosis with recent clinical relapses or MRI activity. The guidelines further note that when a patient shows breakthrough disease activity, such as continued relapses and/or MRI activity, trying a medication with a different mechanism or efficacy profile may be beneficial.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Kesimpta. The American Academy of Neurology (AAN) issued practice guideline recommendations for disease-modifying therapies (DMTs) for patients with multiple sclerosis. Multiple studies of DMTs in people with relapsing forms of multiple sclerosis who have had recent relapses or magnetic resonance imaging (MRI) activity, or both have shown the benefit of DMT in terms of reducing relapses and reducing MRI activity. The AAN guidelines state that providers should offer DMTs to patients with relapsing forms of multiple sclerosis with recent clinical relapses or MRI activity. Some experts recommend patients with relapsing-remitting multiple sclerosis be treated with one of the high-efficacy DMTs, such as natalizumab, ocrelizumab, or ofatumumab.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Kesimpta, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY