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

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 patients 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. The AAAAI states that OIT is not a curative therapy and that individuals who receive OIT will continue to carry epinephrine and read labels closely. The AAAAI states that it is not expected that OIT will lead to ingestion of the allergen without limitation. The current standard of care for treatment of food allergy is avoidance of the allergen and treatment of anaphylaxis with auto-injectable epinephrine. Regarding the effectiveness of OIT, the AAAAI states that efficacy in clinical trials has typically been defined by induction of a desensitized state. Desensitization refers to the improvement in food challenge outcomes after therapy and relies on ongoing exposure to the allergen. Peanut, egg and milk OIT have been shown to desensitize approximately 60 to 80% of patients studied. The AAAAI states that it is important to note that because efficacy has been measured using oral food challenges in trials, it is not yet definitively known whether desensitization can protect patients from real-world accidental exposures. Wang and Bird have noted that there is no consensus on the OIT procedure, including dosing schedule, maintenance dose and treatment duration. They also state that OIT is not expected to be a cure for food allergy, as data show that treatment does not lead to a permanent state of immunologic remission after therapy is discontinued. Sampson and colleagues note that the primary therapy for food allergy is still strict avoidance of the causal food or foods. This is true for all types of food allergy, including immunoglobulin E (IgE)-mediated and nonIgE-mediated food allergy. Therefore, the requested oral immunotherapy treatment is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in allergy and immunology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.