MS Phenotypes, ICD-10 Codes, and Payer Barriers to Treatment

"MS Phenotypes, ICD-10 Codes, and Payer Barriers to Treatment" examines whether a continuum view of MS conflicts with the categories that payers and coding systems use.

Dr. Nair notes that clinicians now discuss MS as a continuum, yet phenotype categories persist, including ICD-10 codes that the MS Society would like to retire. She asks whether payers using these categories creates a disconnect.

Dr. Newsome calls the situation complicated. He understands that payers want guardrails around very expensive drugs that can harm people. Still, when a patient is declining on a particular agent, clinicians first confirm the diagnosis, since misdiagnosis remains common. Then they review the available treatments. He describes being blocked from appropriate therapy because notes documented progression without a relapse in three years, and the drug was labeled for relapsing MS. He points out that technically all forms of MS are relapsing at some point.

Dr. Newsome also describes patients who show zero macroscopic inflammatory activity on the best available therapies yet begin to progress. He considers them the largest unmet need and thinks they likely require combination therapy.

Dr. Longbrake says clinicians who treat MS daily find payer rules frustrating, but she sees the other side. General neurologists outside centers of excellence face access barriers, so care varies by region.

Dr. Freeman suggests the ICD-10 system should reflect cumulative risk. Qualifiers added to a main diagnosis could capture relapse risk and progression risk without dropping patients into eight separate buckets.

Dr. Newsome closes by describing payers who argue that a patient no longer needs a drug because relapses have stopped. He counters that stability is the result of treatment, and withdrawing it takes away a lifeline that keeps people employed and active.

In "Early High-Efficacy Therapy in MS: Escalation, De-Escalation, and Ongoing Trials," the panel will discuss how practice has shifted toward early high-efficacy treatment and what trials may reveal.