Diagnosis: Evans syndrome.
Treatment: Retacrit 4000Unit/ML IJ SOLN, Pre-service.
The insurer denied the Retacrit 4000Unit/ML IJ SOLN, Pre-service.
The denial is overturned.

The patient is a male with a history of Evans syndrome, a form of hemolytic anemia and thrombocytopenia. He is being treated with steroids. The provider is recommending treatment with Retacrit.

Yes, the treatment with Retacrit is medically necessary.
Evans syndrome (ES) is a rare hematologic disorder characterized by the development of autoimmune hemolytic anemia (AIHA), idiopathic thrombocytopenia (ITP), and occasionally immune-mediated neutropenia. The acute management of ES (Evans syndrome) often consists of blood product transfusion in addition to high-dose steroids and intravenous immunoglobulin (IVIG). Erythropoietin has been shown to be effective in the treatment of autoimmune anemia. EPO (erythropoietin) therapy was able to increase Hemoglobin levels (median Hemoglobin increase greater than 2 g/dL [grams per deciliter]) in more than 70% of patients, both frontline and in relapsed/refractory chronic disease.

The health plan did not take into account that the patient was on steroids. The use of erythropoietin would be expected to allow the patient to wean off steroids and avoid the long term complications of steroids. It would therefore be in the best interest of the patient to be treated with erythropoietin at this time.

The patient currently has been on steroids with response in his hemoglobin, which would decrease if the steroids are discontinued. The use of erythropoietin would be expected to allow the patient to wean off steroids and avoid the long term complications of steroids.