Oral Immunotherapy denials in California external review
In the California DMHC record, independent physician reviewers decided 13 published external-review cases involving Oral Immunotherapyand overturned the plan’s denial in 0%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Oral Immunotherapy denials
| Category | Decisions | Overturned |
|---|---|---|
| Food Allergy | 5 | 0% |
What the reviewers wrote
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oral immunotherapy treatment.Findings: Three out of three physician reviewers found that the requested oral immunotherapy treatment is not likely to be more beneficial than any other available standard treatments for the patient’s medical condition.The American Academy of Allergy, Asthma & Immunology (AAAAI) states that Oral Immunotherapy (OIT) refers to feeding an allergic individual an increasing amount of an allergen with the goal of increasing the threshold that triggers a reaction. The goal of therapy is to raise the threshold that may trigger a reaction and provide the allergic individual protection against accidental ingestion of the allergen.
Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for sublingual immunotherapy and/or food tolerance induction. The records provided for review document that this patient has a history of food allergies for which his provider has recommended oral immunotherapy. However, there is a lack of published peer-reviewed literature, scientific evidence, or professional standard guidelines supporting the safety and efficacy of food allergy oral immunotherapy. The newly available, U.S. Food and Drug Administration (FDA) approved oral immunotherapy treatment Palforzia, was not included in the treatment plan for this patient, who has a diagnosis of allergy to peanut. With the exception of Palforzia, there are no other FDA-approved oral immunotherapy/desensitization treatments available.
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 Oral Immunotherapy, 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