A review of the records reveals the member to be an adult female with a birth date of 06/06/1956. The member has a diagnosis of rheumatoid arthritis. The member’s treating provider, Laura Summers, MD recommended the member continue her treatment of Remicade infusions 7 mg/kg every 6 weeks.
The carrier has denied coverage of Remicade infusions 7 mg/kg every 6 weeks as not medically necessary. There is a letter from the carrier to the member dated 02/01/2016, which states in part:
“I must regretfully inform you that after giving careful consideration to all of this information, the trustees have determined that they must deny your appeal. Their decision was based upon the fact that they are required by federal law to administer the plan …show more content…
Her joint symptoms have continued to decline since then. Debra has progressive joint pain and swelling which is affecting her activities of daily living, she no longer able to dress herself or climb stairs without great difficulty.
I say all this to express to you the urgency in this matter. Debra is declining at a rapid pace and is in need of aggressive treatment. I believe she would benefit from Remicade in order to halt the rapid progression of her Rheumatoid Arthritis...”
Final External Review Decision:
The carrier’s decision in denying coverage for continued Remicade infusions 7 mg/kg every 6 weeks was not appropriate.
The request to continue Remicade infusions 7 mg/kg every 6 weeks is medically necessary for the treatment of this member’s condition.
Therefore, the previous denial should be overturned.
Findings:
The member is a 59-year-old woman who carries the diagnosis of sero-negative Rheumatoid Arthritis (RA). The issue in this case is whether continued infliximab (Remicade) infusions 7 mg/kg every 6 weeks are medically …show more content…
Remicade, Simponi, and Orencia were considered substitutes for Enbrel. Initial approval for Remicade was submitted and approved since it was started with initial good clinical response and plans to reduce the member’s Medrol. Laboratory Studies in October 2015, again were negative for RA testing (type not specified) but positive ANA and SS-A. The dose of Remicade had been slowly escalated to 7mg/kg because of exacerbations of the member’s polyarthritis. In December 2015, the member’s Medrol dosage was increased. Her HAQ score had increased to 1625 and her CRP was elevated to 5.49
The carrier has denied coverage of Remicade infusions 7 mg/kg every 6 weeks as not medically necessary. There is a letter from the carrier to the member dated 02/01/2016, which states in part:
“I must regretfully inform you that after giving careful consideration to all of this information, the trustees have determined that they must deny your appeal. Their decision was based upon the fact that they are required by federal law to administer the plan …show more content…
Her joint symptoms have continued to decline since then. Debra has progressive joint pain and swelling which is affecting her activities of daily living, she no longer able to dress herself or climb stairs without great difficulty.
I say all this to express to you the urgency in this matter. Debra is declining at a rapid pace and is in need of aggressive treatment. I believe she would benefit from Remicade in order to halt the rapid progression of her Rheumatoid Arthritis...”
Final External Review Decision:
The carrier’s decision in denying coverage for continued Remicade infusions 7 mg/kg every 6 weeks was not appropriate.
The request to continue Remicade infusions 7 mg/kg every 6 weeks is medically necessary for the treatment of this member’s condition.
Therefore, the previous denial should be overturned.
Findings:
The member is a 59-year-old woman who carries the diagnosis of sero-negative Rheumatoid Arthritis (RA). The issue in this case is whether continued infliximab (Remicade) infusions 7 mg/kg every 6 weeks are medically …show more content…
Remicade, Simponi, and Orencia were considered substitutes for Enbrel. Initial approval for Remicade was submitted and approved since it was started with initial good clinical response and plans to reduce the member’s Medrol. Laboratory Studies in October 2015, again were negative for RA testing (type not specified) but positive ANA and SS-A. The dose of Remicade had been slowly escalated to 7mg/kg because of exacerbations of the member’s polyarthritis. In December 2015, the member’s Medrol dosage was increased. Her HAQ score had increased to 1625 and her CRP was elevated to 5.49