Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 54-year-old female with multiple sclerosis (MS) diagnosed 12 years ago.  There has been significant progression of the disease over the past eighteen months and she was diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP).  The patient experienced severe right-sided weakness and a course of IVIG did not improve her symptoms. She underwent five days of plasmapheresis and regained strength in her lower extremities. The patient now requests reimbursement for the plasmapheresis.  The Health Plan considers the therapy experimental/investigational and has denied coverage.In patients with MS and CIDP, the latter condition is usually treated with IVIG as a first step. If the patient does not respond beneficially, as was the case with this patient, plasmapheresis is the next step and is frequently effective. The treatment has been the subject of numerous studies and publications and proven to be effective in the treatment of CIDP (Hahn et al). Plasmapheresis was the appropriate treatment in this patients case. Therefore, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 54-year-old woman with severe multiple sclerosis (MS) and chronic inflammatory demyelinating polyneuropathy (CIDP).  Her symptoms have failed to improve with IVIG and steroid treatments.  She was recently treated with plasmapheresis while an inpatient, and had a notable improvement in her strength.  She is also treated with the standard therapies for MS.  The patient has requested reimbursement for the cost of the plasmapheresis.  The Health Plan denied the request based upon a determination that the therapy is experimental/investigational for the treatment of the patients condition.This patient has a rapidly progressive form of MS and a diagnosis of CIDP reportedly confirmed with EMG. Treatment with intravenous (IV) steroids and IVIG had not resulted in resolution of her symptoms.  The efficacy of plasma exchange in the treatment of CIDP is well-documented in the literature and it has also been shown to be effective in the treatment of severe MS exacerbations. The patient has a condition that is the combined result of central and peripheral demyelination (MS and CIDP), which has been described as refractory to the usual MS treatments.  Plasmapheresis was likely to be more beneficial for her treatment than any available standard therapy. Accordingly, the Health Plans denial should be overturned.Physician 3: This patient is a 54-year-old female who has a history of neurological symptoms dating back to 1977 and was diagnosed with multiple sclerosis (MS) in 1993.  She also has a more recent diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP). She had symptoms of progressive weakness, spasticity and dyspnea when admitted to the hospital. She was noted to have atrophy in her hands and an EMG reportedly showed neuropathy consistent with a diagnosis of CIDP. The patients MS has been treated with Copaxone and her CIDP was treated with IVIG, which was seemingly without benefit. Physical findings as documented have been a mixture of upper motor and lower motor neuron features fitting the diagnoses previously noted.  She was plasmapheresed as an inpatient, and apparently tolerated the therapy well with improved strength reported in the progress notes.  The Health Plan has denied coverage for the therapy citing its experimental/investigational nature. Treatment of the patients CIDP with IVIG was unsuccessful and did not result in improved strength on her right side. The medical literature demonstrates that plasmapheresis, along with concurrent immunosuppressive therapy, is beneficial in the treatment of CIDP and is an accepted and appropriate treatment for this clinical situation.Additionally, plasmapheresis has been shown to be particularly efficacious in patients with MS and severe relapses not responsive to methylprednisolone. Based upon the information set forth above, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.