While I usually agree with Bill Nemitz, I take issue with his perspectives regarding Anthem’s denial of insurance coverage for rituximab treatment of Roger Morse’s myasthenia gravis (MG) and the two independent physician reviewers (“outsiders”), both retired and in their 70’s. I am a member of Mr. Nemitz’s derided group of retired older physicians and occasionally am such a reviewer. When I practiced neuromuscular neurology I served on the Medical Advisory Board of the Myasthenia Gravis Foundation.

At present Anthem has several understandable reasons for this denial:

• Rituximab is not FDA-approved for MG; it is currently an ‘experimental therapy’ in MG. Only about 200 rituximab-treated MG patients have been reported in the medical literature, none in randomized controlled trials – the standard method to determine efficacy (several trials are underway but not completed);

• Reviews of rituximab treatment of MG suggest it be reserved for patients with severe disease refractory to other immunosuppressive therapies. That Mr. Morse can no longer run the Beach to Beacon 10k race is not indicative of severity; respiratory or swallowing difficulties, or considerable limb weakness would be;

• Patients with the most common antibody in MG (to AChR, ~80 percent) seem not very responsive to rituximab (30 percent), whereas patients with a rarer antibody (to MuSK, ~7 percent) do better (72 percent). If Mr. Morse is in the AChR group and not disabled with respiratory, swallowing or significant limb weakness it is understandable why coverage for rituximab was denied. Finally, Anthem did provide insurance coverage for a thymectomy and other immunosuppressive therapies for which Mr. Nemitz gives it no credit.

I am not in the position to advocate for or against Mr. Morse’s use of rituximab. He may benefit from it. But in today’s medical climate, Anthem’s denial is not nefarious and its reviewers not incompetent. Mr. Nemitz has been more informed on other subjects in the past.

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