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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage for intravenous immunoglobulin (IVIG) infusions (Gammagard 86 grams divided over three days every four weeks) provided, and prospective authorization and coverage for IVIG infusions (Gammagard 86 grams divided over three days every four weeks). Pediatric acute-onset neuropsychiatric syndrome (PANS) is defined by the sudden onset of obsessive compulsive disorder (OCD) or eating restrictions and comorbid symptoms. Acute onset cases that are triggered by Group A streptococcal infections may meet diagnostic criteria for both PANS and pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). These two syndromes display highly similar symptoms and guidelines often treat them as a single entity (Thienemann, et al.). The treatment of PANDAS involves approaching both the physical and psychiatric symptoms. Treatment must reduce the symptoms of OCD such as the tics or other behaviors that could interfere with day to day living and school. The treatment of the streptococcal infection is performed with antibiotics and the psychiatric symptoms can begin to improve upon the start of the antibiotic treatment. The OCD and other psychiatric symptoms are generally treated with the cognitive behavioral therapy and/or selective serotonin reuptake inhibitors. Some severe cases of PANDAS may not respond to medical and behavioral therapy. In such cases, immunomodulating therapies, individually or in combinations may be indicated (Frankovich, et al.). The records provided for review document that this patient has been diagnosed with PANS/PANDAS and autoimmune encephalopathy that has not responded to other treatments, including psychotropic medications and steroids. The provider reported that the patient experienced a positive response to IVIG. In this clinical setting, there is sufficient evidence in the medical literature and in the clinical response of the patient to support the use of IVIG as an efficacious treatment. Therefore, the IVIG infusions (Gammagard 86 grams divided over three days every four weeks) provided, and prospective authorization and coverage for IVIG infusions (Gammagard 86 grams divided over three days every four weeks) were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the IVIG infusions (Gammagard 86 grams divided over three days every four weeks) provided, and prospective authorization and coverage for IVIG infusions (Gammagard 86 grams divided over three days every four weeks) were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry  and is actively practicing. Physician reviewer 2 is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. Physician reviewer 3 is board certified in neurology with special qualification in child neurology and is 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.