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

Physician 1The patient is a 36-year-old man with focal weakness and EMG denervation, particularly in the proximal right upper extremity. The patient has a presumed diagnosis of multifocal motor neuropathy. The patient has experienced some improvement with IVIG. The patient has received Rituxan therapy in the past and wishes to continue to receive Rituxan. The Health Plan has denied authorization for the requested therapy indicating that Rituxan is considered experimental in nature.The Health Plans denial should be upheld. Rituxan is considered experimental in treatment of neuropathies. In addition, based upon the information provided the patients diagnosis is not conclusive. IVIG is the standard treatment for the patients symptomatology and the patient appears to have benefited from a prior course of IVIG. There is no evidence that Rituxan will be more beneficial for the patients condition than continued use of IVIG. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. As such, the Health Plans denial should be upheld.Physician 2The patient is a 36-year-old man with multifocal motor neuropathy, an autoimmune neurological disorder (frequently referred to as chronic inflammatory demyelinating polyradiculoneuropathy or CIDP). The patient wishes to continue treatment with Rituxan, an immunomodulator used predominantly for the treatment of lymphoma. The Health Plan has denied the patients request.Rituxan has not been approved by the Food and Drug Administration for treatment of CIDP. At this time, there is no convincing medical literature that Rituxan is safe and effective for long-term treatment of CIPD. The patient has been previously treated with IVIG with partial success. Rituxan is not likely to be of greater benefit for the patient than IVIG, which is presently used and approved for treatment of CIPD.  Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 36-year-old man with a five-year history of multifocal motor neuropathy with mild weakness, which has responded to IVIG. The patient received a course of IVIG in February 2003. He received Rituxan in June 2003 and now has mildly progressive symptoms. Another course of IVIG has been recommended. The patient has requested coverage for Rituxan therapy. The Health Plan has denied the patients request indicating that the requested therapy is investigational in nature.The patient has been stable on quarterly IVIG. There are no scientific studies to suggest that Rituxan is useful in multifocal motor neuropathy. Even if Rituxan may be helpful, it should only be used in patients who are progressing despite routine IVIG and/or Cytoxan. Standard treatments for multifocal motor neuropathy including IVIG and Cytoxan are likely to be of greater benefit than Rituxan, which appears to have little or no therapeutic role in this patients condition.  Based upon the information set forth above, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.