[CIS PIDD] [cis-pidd] RTX and hypogamma

[Seppänen Mikko]

Dear James,

Somewhat but not totally outside Medicare issues (changed the topic though):

In follow up it -if permanent - looks so much like CVID,


1)      see Immunology Letters Kano G et al. Complicated pathophysiology behind rituximab-induced persistent hypogammaglobulinemia (I think still in press) and

2)      an in press editorial/brief review about this, among other things (Seppänen M, Aghamohammadi A, Rezaei N. Expert Rev Clin Immunol. )

I would however argue that it may be reversible in 18(-24?) mo and that quite a few of them actually develop some form of hypogamma, and I would not be eager to treat the milder cases, see Clin Lymphoma Myeloma Leuk 2013; 13 (2):106-111 for figures?

Is anyone aware of any other studies on how many of RTX (/other B-cell -ab) -treated get hypogamma?

Mikko Seppänen, MD PhD
Helsinki

Lähettäjä: Kirkpatrick, Charles [mailto:Charles.Kirkpatrick at ucdenver.edu]
Lähetetty: 3. joulukuuta 2013 23:47
Vastaanottaja: CIS-PIDD
Aihe: RE: [cis-pidd] medicare IVIG question

I have several similar patients.  I have used 279.06 with Medicare successfully.

The general literature tells us that prolonged B-cell deficiency and clinically significant immune deficiency is rare.  Not in Clinical Immunology Clinics.   It has been 9 years since any chemotherapy for one of my patients.
She still has no memory B-cells and does not make antibodies.  IgG infusions are essential for her.

Chuck Kirkpatrick

From: James L. Friedlander, M.D. [mailto:jfriedlander at allergyasthmaimm.com]
Sent: Tuesday, November 26, 2013 1:58 PM
To: CIS-PIDD
Subject: [cis-pidd] medicare IVIG question

I have several Medicare patients with B cell lymphoma treated with rituximab that develop recurrent sinopulmonary infections during/after treatment, along with significant hypogammaglobulinemia and non-protective antibody titers.  Medicare is requiring one of the diagnoses listed below before they will approve treatment with immune replacement.

279.04 Congenital hypogammaglobulinemia
279.05 Immunodeficiency with increased IgM
279.06 CVID
279.12 WAS
279.2 Combined ID

I would argue that none of these are correct, as these patients clearly have drug-induced immunodeficiency.  Listing hypogammaglobulinemia alone or in combination with antibody deficiency for diagnosis codes does not work for Medicare, but this has worked for some private insurance companies.

Anyone else come across this issue?  Thanks.

Jim Friedlander
Omaha, NE
















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