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201906-117944

2019

CVS Caremark

Self-Funded

Vision

Pharmacy/ Prescription Drugs

Medical necessity

Upheld

Case Summary

The patient has a listed diagnosis of optic neuritis. Records indicate she had an episode of left eye blurry vision, which was diagnosed as an optic neuritis.

The health plan's determination is upheld. There is insufficient literature evidence to support the use of IVIG (Gammagard Liquid) in the treatment of optic neuritis. This is not considered standard of care and is not generally recommended. It is not part of any current societal recommendations or guidelines.

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