Oral Immunotherapy denials: what the review data shows

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.

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