Tx For Allergies denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 57-year-old male with moderate to severe allergic asthma and chronic sinusitis, with seasonal and year-round allergies. He has tried various medications but has been unresponsive to standard medical treatments. His lung function tests revealed a low FEV1.The patient underwent skin testing in 1997 with positive results to trees, grasses and weeds. His IgE level was reported as 39.1 IU/ml in May 1997. The patient’s current medications include Advair, Singulair, Flonase, Nexium, Zyrtec, Optivar, and Duratuss. He has also received a variety of other medications, including inhaled corticosteroids, theophylline and long-acting beta-agonists. Review of progress notes indicate the patient was taking 20mg prednisone in April 2002, indicating severe steroid dependency.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pollen and allergy injections performed weekly for treatment of the enrollee’s allergic rhinitis and asthma. Findings: The physician reviewer found that based on the available documentation, the service of immunotherapy dosed at once weekly intervals meets the current criteria for medical necessity and is within the standard of care for providing immunotherapy injections to a patient who is symptomatic with asthma and allergic rhinitis. Review of the record shows sufficient documentation to support the increased dosing. There was allergy skin testing done with positive findings for several allergens. Clinic notes from provider indicate that the patient was actively taking multiple medications for rhinitis and asthma.

Where the denial was upheld

The patient is a 54-year-old female with a history of asthma and allergies. The patient’s provider indicates the patient has specific IgE disease with a pre-Xolair IgE of 3. In addition, the provider notes the patient has positive allergy testing. The patient’s pulmonary function tests showed an FEV1 of 71% and a post-test FEV1 of 82% showing reversibility. In May 2004, the patient was taking Advair 500/50, Singulair, and Combivent inhaler. She was also taking Zyrtec D, Diflucan QD, Tamoxifen, Prednisone, and Albuterol nebulizer. The submitted notes indicate the patient was experiencing exacerbations and urgent unscheduled visits to her physician.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly allergy shots for treatment of the enrollee who has sensitivity to numerous allergens. Findings: The physician reviewer found that Subcutaneous allergen immunotherapy (AIT) is a treatment for allergic rhinitis, allergic conjunctivitis, allergic asthma, and stinging insect hypersensitivity that induces immune modulation by administration of gradually escalating doses of allergen. Conventional allergen immunotherapy schedules involve a build up phase and a maintenance phase, at which time the maintenance dose is reached. The maintenance dose, or effective dose, is that which is believed to “provide therapeutic efficacy without significant adverse local or systemic reactions”.

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 Tx For Allergies, then check the rights and deadlines that apply to your plan.