California Health Benefits Review Program Abbreviated Analysis of California Assembly Bill 907 Coverage for PANDAS and PANS

Abstract

The California Assembly Committee on Health has requested that the California Health Benefits Review Program (CHBRP)7 conduct an evidence-based assessment of the medical, financial, and public health impacts of AB 907, coverage of PANDAS and PANS, as amended on March 16, 2023.

Full text

California Health
Benefits
Review Program
Analysis of California Assembly Bill 907
Coverage for PANDAS and PANS
A Report to the 2023–2024 California State Legislature April 20, 2023

Current as of April 20, 2023 www.chbrp.org i
Key Findings
Analysis of California Assembly Bill 907
Coverage for PANDAS and PANS
Summary to the 2023–2024 California State Legislature, April 20, 2023
AT A GLANCE
The version of California Assembly Bill 907 analyzed
by CHBRP would require health plans regulated by
the Department of Managed Health Care (DMHC)
and health policies regulated by the California
Department of Insurance (CDI) to provide coverage
for the prophylaxis, diagnosis, and treatment of
Pediatric Autoimmune Neuropsychiatric Disorder
Associated with Streptococcal Infections (PANDAS)
and Pediatric Acute-onset Neuropsychiatric
Syndrome (PANS).
In 2024, 100% of the 22.8 million Californians
enrolled in state-regulated health insurance would
have insurance subject to AB 907.
Benefit Coverage: At baseline, 100% of enrollees
with health insurance subject to AB 907 have
coverage that includes diagnostic tests
recommended by various guidelines related to
PANDAS/PANS and would continue to have 100%
coverage postmandate. At baseline, 100% of
enrollees with health insurance subject to AB 907
would have coverage for antibiotics, oral prescription
immunomodulatory medications, and behavioral
therapies and medications for managing
neuropsychiatric symptoms, consistent with
recommendations for treatment of PANDAS/PANS
under existing clinical guidelines, and 0% have
coverage for intravenous immunomodulating
therapies, including plasma exchange and
intravenous immunoglobulin (IVIG) therapy;
postmandate 100% would have coverage for the
aforementioned treatments. AB 907 would not be
likely to exceed essential health benefits (EHBs).
Medical Effectiveness: CHBRP found insufficient
evidence that the treatments recommended by
clinical guidelines were effective at reducing or
eliminating prominent symptoms of pediatric patients
with PANDAS/PANS, with the exception of
antibiotics and IVIG; the evidence of the
effectiveness of these two treatments for eliminating
or reducing symptoms was inconclusive.
1
Similar cost and health impacts could be expected for the
following year, though possible changes in medical science
Cost and Health Impacts1: In 2024, AB 907 would
result in approximately an additional $2.99 million (or
0.002%) in annual expenditures due to an estimated
additional 90 enrollees utilizing IVIG, 0 additional
enrollees utilizing plasma exchange, and an
additional 22 enrollees utilizing other intravenous
immunomodulating therapy (i.e., rituximab), as
treatment for PANDAS/PANS.
The public health impact of AB 907 is unknown due
to insufficient and inconclusive evidence regarding
the effectiveness of treatments for PANDAS/PANS.
CONTEXT
PANDAS/PANS are terms used to describe a subset of
children with symptoms that include a sudden onset of
obsessive-compulsive disorder (OCD) and/or tic
disorders co-occurring with a collection of
neuropsychiatric symptoms usually following an
infection.
2
Children may also become moody or irritable,
or experience anxiety attacks, separation anxiety, rage,
fatigue, phobias, insomnia, joint or muscle pain, or
eating disorders.
PANDAS, currently classified as a subset of PANS, is
hypothesized by some to be triggered by an autoimmune
response to Group A Streptococcal bacteria (which
cause strep throat or soft tissue infections). PANS is
hypothesized to be triggered by causes other than
Group A Streptococcus infection. Much remains
unknown about PANDAS and PANS, and controversy
remains regarding whether PANDAS differs enough from
OCD/tic disorder and other neuropsychiatric disorders to
warrant a different diagnostic category.
PANDAS/PANS has been primarily described in children
between the ages of 3 and 12 years; however, the exact
prevalence and age distribution of PANDAS/PANS is
unknown. People over the age of 17 may also present
with symptoms similar to those of PANDAS and PANS
or have an initial diagnosis of either syndrome at a
pediatric age that continues into adulthood. Because
OCD is a required symptom for the diagnosis of
and other aspects of health make stability of impacts less
certain as time goes by.
2
Refer to CHBRP’s full report for citations and references.

Key Findings: Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org ii
PANDAS and PANS, it is thought their prevalence can
be estimated as a subset of the prevalence of pediatric
OCD. Epidemiological research estimates that 0.5% to
5% of children in the United States are affected by OCD.
One study estimates that 5% of children with OCD may
meet the criteria for PANS/PANDAS.
CHBRP identified 3 clinical practice guidelines that meet
AB 907’s criteria for diagnosing and treating patients
with PANDAS/PANS, on which it based this analysis.
There is no specific diagnostic test to confirm a
diagnosis for PANDAS or PANS, and other conditions
may present with similar symptoms, making it a difficult
to reliably diagnose and study PANDAS/PANS.
Clinicians use a differential diagnostic process that
includes collecting a patient’s medical history,
conducting a physical exam, and may include diagnostic
tests to rule out other conditions with similar symptoms.
Additional tests may include testing for Group A
Streptococcus, or Mycoplasma pneumoniae – infections
that may be associated with PANDAS or PANS.
Per existing clinical guidelines, treatment options for
PANDAS/PANS depend on the physical and/or
neuropsychiatric symptoms experienced by the patient.
The guidelines include treatments with: antibiotics;
nonsteroidal anti-inflammatory drugs (NSAIDs);
corticosteroids; cognitive behavioral therapy (CBT);
psychotropics; intravenous immunoglobulin (IVIG); other
immune-modulators (rituximab, mycophenolate mofetil);
therapeutic plasma exchange; and vitamin D.
BILL SUMMARY
AB 907, as amended on March 16, 2023, would require
Department of Managed Health Care (DMHC)-regulated
health plans and California Department of Insurance
(CDI)-regulated health policies to provide coverage for
the prophylaxis, diagnosis, and treatment of PANDAS
and PANS. Covered treatments must include antibiotics,
medications and behavioral therapies to manage
neuropsychiatric symptoms, immunomodulating
medicines, plasma exchange, and intravenous
immunoglobulin therapy. The bill also requires coverage
to abide by several terms and conditions, including: 1) a
prohibition on limitations to coverage for
immunomodulating therapies for PANDAS/PANS in a
manner inconsistent with clinical practice guidelines and
evidence-based standards for diagnosis and treatment
of PANDAS/PANS; and 2) a prohibition on a mandate for
step therapy to treat only neuropsychiatric symptoms
prior to authorization of coverage for immunomodulating
therapies.
Figure A notes how many Californians have health
insurance that would be subject to AB 907.
Figure A. Health Insurance in CA and AB 907
Source: California Health Benefits Review Program, 2023.
Key: CDI = California Department of Insurance; COHS = County
Organized Health System; DMHC = Department of Managed Health
Care.
IMPACTS
Medical Effectiveness
CHBRP analyzed the strength of evidence for the
effectiveness of antibiotics, psychotropic medications,
cognitive behavioral therapy, plasma exchange, IVIG
and other immunomodulating medications addressed by
AB 907, specifically, for children affected by
PANDAS/PANS.
Overall, the evidence is insufficient or inconclusive that
any of these treatments are effective at reducing
prominent symptoms, such as OCD symptoms, tics, or
eating restrictions, for pediatric patients with
PANDAS/PANS.
The body of research on PANDAS and PANS is small
(number of studies and sample sizes of available
studies) compared with many other diseases and
conditions. Additional studies involving controlled clinical
trials, larger sample sizes, and clear eligibility criteria are
necessary to determine which treatments are effective
for children with PANDAS/PANS.

Key Findings: Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org iii
More specifically, CHBRP found insufficient evidence
3
on the effectiveness of CBT, psychotropics, NSAIDs,
corticosteroids, plasma exchange, rituximab,
mycophenolate mofetil, and vitamin D in reducing or
eliminating the prominent symptoms associated with
PANDAS/PANS.
CHBRP found inconclusive evidence
4
on the
effectiveness of antibiotics and IVIG in reducing or
eliminating the prominent symptoms associated with
PANDAS/PANS.
Each of the medications reviewed for this analysis is
associated with a variety of side effects and harms. See
Table 3 of the full report for more details.
Benefit Coverage, Utilization, and Cost
Benefit Coverage
At baseline, 100% of enrollees with health insurance that
would be subject to AB 907 have coverage that includes
diagnostic tests associated with PANDAS/PANS
recommended by various guidelines for diagnosing
PANDAS/PANS.
At baseline, 100% of enrollees with health insurance that
would be subject to AB 907 have coverage that includes
some, but not all, treatments for PANDAS/PANS.
Coverage by type of treatment varies substantially.
CHBRP found that 100% of enrollees have health
insurance that includes antibiotics commonly used for
PANDAS/PANS and some oral prescription
immunomodulatory medications including steroids and
nonsteroidal anti-inflammatory medications (NSAIDs).
Similarly, 100% of enrollees have health insurance that
includes coverage for psychotropics used for treatment
of neuropsychiatric symptoms of PANDAS/PANS,
including selective serotonin receptor inhibitors (SSRIs),
benzodiazepines, and antipsychotics. One hundred
percent of enrollees also have health insurance that
includes coverage of behavioral health therapies used
for treatment of neuropsychiatric symptoms of
PANDAS/PANS, including cognitive behavioral therapy
(CBT). CHBRP finds that 0% of enrollees have coverage
for intravenous immunomodulating therapies, including
plasma exchange, B-cell modulators (rituximab), and
intravenous immunoglobulin (IVIG) therapy.
3
Insufficient evidence indicates that there is not enough
evidence available to know whether or not a treatment is
effective, either because there are too few studies of the
treatment or because the available studies are not of high
quality. It does not indicate that a treatment is not effective.
Postmandate, 100% of enrollees with health insurance
subject to AB 907 would have coverage for all diagnostic
tests and treatments included under the bill.
Utilization
CHBRP estimates that at baseline, 15,410 enrollees use
diagnostic tests for PANDAS/PANS. These include
various blood tests, throat cultures, and nose swabs.
CHBRP estimates that for every 23 children tested for
PANDAS/PANS using these diagnostic tests, 1 child is
diagnosed with PANDAS/PANS and 22 children are not
given this diagnosis. Given that 100% of enrollees
already have baseline coverage, CHBRP estimates no
changes in utilization for these diagnostic tests.
At baseline, CHBRP estimates that 670 enrollees have a
PANDAS/PANS diagnosis. Among these enrollees,
average annual utilization of oral prescription
medications used for the treatment and management of
neuropsychiatric symptoms (including medications such
as antibiotics, steroids, NSAIDs, and psychotropics) is
17.8 prescriptions, each with a 30-day supply. At
baseline, annual utilization of CBT is 20 visits per year.
Given that 100% of enrollees already have baseline
coverage for these medications and behavioral health
therapies such as CBT, CHBRP estimated no changes
in utilization of these specific medications and CBT
services postmandate.
CHBRP estimates that IVIG, rituximab, and plasma
exchange have extremely limited use at baseline.
CHBRP estimates that average annual utilization of IVIG
among all enrollees with PANDAS/PANS would increase
to 0.7 infusion therapy sessions per year. This results in
an estimated 90 enrollees with moderate or severe
PANDAS/PANS utilizing IVIG at least once per year,
with greater expected utilization among those with
severe PANDAS/PANS. CHBRP estimates that average
annual utilization of rituximab would increase to 0.1
infusion therapy sessions. This results in an estimated
22 enrollees with severe PANDAS/PANS utilizing an
estimated average of 3 rituximab infusions per year.
CHBRP estimated no change in the use of plasma
exchange services given their low availability and the
lack of evidence of their effectiveness in
PANDAS/PANS.
4
Inconclusive evidence indicates that although some studies
included in the medical effectiveness review find that a
treatment is effective, a similar number of studies of equal
quality suggest the treatment is not effective.

Key Findings: Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org iv
Expenditures
AB 907 would increase total net annual expenditures by
total net annual $2,990,000 or total net annual 0.0020%
for enrollees with DMHC-regulated plans (including
DMHC-regulated Medi-Cal) and CDI-regulated policies.
Figure B. Expenditure Impacts of AB 907
Source: California Health Benefits Review Program, 2023.
Medi-Cal
For this analysis, CHBRP has included potential impacts
on Medi-Cal beneficiaries. In addition to the expected
increase of $1.47 million in premiums CHBRP is
estimating for the 8.8 million Medi-Cal beneficiaries
enrolled in DMHC-regulated plans (a figure that
represents a 0.005% increase in premiums), it seems
reasonable to assume that a population proportional
increase of $370,000 would occur for the 2.0 million
beneficiaries enrolled in county organized health
systems (COHS) managed care.
CalPERS
For enrollees associated with CalPERS in DMHC-
regulated plans, premiums would increase by 0.001%
($0.01 per member per month, or $83,000 total increase
in expenditures).
Covered California – Individually Purchased
Premiums for enrollees in individual plans purchased
through Covered California would increase by a total of
$69,000 in annual expenditures.
Number of Uninsured in California
Because the change in average premiums does not
exceed 1% for any market segment, CHBRP would
expect no measurable change in the number of
uninsured persons due to the enactment of AB 907.
Public Health
In the first year postmandate, the public health impact of
AB 907 is unknown due to insufficient and inconclusive
evidence regarding the effectiveness of treatments for
PANDAS/PANS. Please note that the absence of
evidence is not “evidence of no effect.” It is possible that
an impact – desirable or undesirable – could result, but
current evidence is insufficient to inform an estimate.
Long-Term Impacts
Utilization of diagnostic tests and treatments for
PANDAS/PANS is expected to be similar in the long
term as utilization in the first 12 months postmandate.
However, should evidence about the effectiveness of
new diagnostic tests or treatments such as IVIG or
rituximab become more conclusive, for example, via
more evidence from larger randomized controlled clinical
trials, more physicians may prescribe these treatments.
Cost impacts are expected to also be similar to those
projected in the first 12 months postmandate.
Due to the dearth of research about PANDAS/PANS,
CHBRP finds an unknown public health impact of AB
907 over the long term.
Essential Health Benefits and the
Affordable Care Act
AB 907 would not require coverage for a new state
benefit mandate that appears to exceed the definition of
EHBs in California.

A Report to the California State Legislature
Analysis of California Assembly Bill 907
Coverage for PANDAS and PANS
April 20, 2023
California Health Benefits Review Program
MC 3116; Berkeley, CA 94720-3116
www.chbrp.org
Suggested Citation: California Health Benefits Review Program (CHBRP). (2023). Analysis of California
Assembly Bill 907 Coverage for PANDAS and PANS. Berkeley, CA.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org vi
The California Health Benefits Review Program (CHBRP) was established in 2002. As per its authorizing
statute, CHBRP provides the California Legislature with independent analysis of the medical, financial,
and public health impacts of proposed health insurance benefit-related legislation. The state funds
CHBRP through an annual assessment on health plans and insurers in California.
An analytic staff based at the University of California, Berkeley, supports a task force of faculty and
research staff from multiple University of California campuses to complete each CHBRP analysis. A strict
conflict-of-interest policy ensures that the analyses are undertaken without bias. A certified, independent
actuary helps to estimate the financial impact. Content experts with comprehensive subject-matter
expertise are consulted to provide essential background and input on the analytic approach for each
report.
More detailed information on CHBRP’s analysis methodology, authorizing statute, as well as all CHBRP
reports and other publications, are available at www.chbrp.org.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org vii
TABLE OF CONTENTS
Policy Context ................................................................................................................................................ 1
Bill-Specific Analysis of AB 907, Coverage of PANDAS and PANS ......................................................... 1
Analytic Approach and Key Assumptions .................................................................................................. 2
Interaction With Existing State and Federal Requirements ....................................................................... 3
Background on PANDAS and PANS ............................................................................................................. 6
What Are PANS and PANDAS? ................................................................................................................ 6
Prevalence of PANDAS/PANS in the United States .................................................................................. 8
PANDAS/PANS Diagnosis and Treatment Path ....................................................................................... 9
Disparities in PANDAS/PANS .................................................................................................................. 11
Medical Effectiveness .................................................................................................................................. 13
Research Approach and Methods ........................................................................................................... 13
Methodological Considerations ................................................................................................................ 14
Outcomes Assessed ................................................................................................................................ 14
Study Findings ......................................................................................................................................... 14
Summary of Findings ............................................................................................................................... 23
Benefit Coverage, Utilization, and Cost Impacts ......................................................................................... 26
Baseline and Postmandate Benefit Coverage ......................................................................................... 27
Baseline and Postmandate Utilization ..................................................................................................... 28
Baseline and Postmandate Per-Unit Cost ............................................................................................... 29
Baseline and Postmandate Expenditures ................................................................................................ 29
Other Considerations for Policymakers ................................................................................................... 31
Public Health Impacts .................................................................................................................................. 36
Estimated Public Health Outcomes ......................................................................................................... 36
Long-Term Impacts ...................................................................................................................................... 38
Long-Term Utilization and Cost Impacts.................................................................................................. 38
Long-Term Public Health Impacts ........................................................................................................... 38
Appendix A Text of Bill Analyzed ............................................................................................................... A-1
Appendix B Literature Review Methods..................................................................................................... B-1
Appendix C Cost Impact Analysis: Data Sources, Caveats, and Assumptions ........................................ C-1
References
California Health Benefits Review Program Committees and Staff
Acknowledgments

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org viii
LIST OF TABLES AND FIGURES
Table 1. Impacts of AB 907 on Benefit Coverage, Utilization, and Cost, 2024 ............................................ ix
Table 2. Treatments Considered for AB 907 Analysis .................................................................................. 2
Table 3. Summary of Evidence of Medical Effectiveness of Test/Treatment/Service................................. 24
Table 4. Baseline Per Member Per Month Premiums and Total Expenditures by Market Segment,
California, 2024 ..................................................................................................................................... 32
Table 5. Postmandate Per Member Per Month Premiums and Total Expenditures by Market Segment,
California, 2024 ..................................................................................................................................... 34
Table 6. ICD-10 Codes Used to Identify PANDAS/PANS Service Utilization ........................................... C-2
Table 7. Distribution of PANDAS/PANS Severity ...................................................................................... C-2
Table 8. Services Included in Estimated Treatment Plans by Severity Level ........................................... C-3
Table 9. Coverage Assumptions of Treatments ........................................................................................ C-4
Figure 1. Common Symptoms of PANDAS/PANS Used for Clinical Diagnosis ............................................ 7
Figure 2. Effectiveness of Antibiotics for Patients With PANDAS/PANS .................................................... 17
Figure 3. Effectiveness of CBT for Patients With PANDAS/PANS ............................................................. 18
Figure 4. Effectiveness of Psychotropics for Patients With PANDAS/PANS .............................................. 18
Figure 5. Effectiveness of NSAIDS for Patients With PANDAS/PANS ....................................................... 19
Figure 6. Effectiveness of Corticosteroids for Patients With PANDAS/PANS ............................................ 20
Figure 7. Effectiveness of IVIG for Patients With PANDAS/PANS ............................................................. 21
Figure 8. Effectiveness of Plasma exchange for Patients With PANDAS/PANS ........................................ 22
Figure 9. Effectiveness of Rituximab for Patients With PANDAS/PANS ..................................................... 23
Figure 10. Effectiveness of Mycophenolate Mofetil for Patients With PANDAS/PANS .............................. 23
Figure 11. Effectiveness of Vitamin D for Patients With PANDAS/PANS ................................................... 23

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org ix
Table 1. Impacts of AB 907 on Benefit Coverage, Utilization, and Cost, 2024
Baseline (2024)
Postmandate
Year 1 (2024)
Increase/
Decrease
Change
Postmandate
Benefit coverage
Total enrollees with health
insurance subject to state-level
benefit mandates (a)
22,842,000
22,842,000
—
0.00%
Total enrollees with health
insurance subject to AB 907
22,842,000
22,842,000
—
0.00%
Total percentage of enrollees with
coverage for diagnostics/treatment
of PANDAS/PANS:
Diagnostics (b)
100%
100%
0%
0.00%
Oral prescription medications
(30-day supply) (c) (d)
100%
100%
0%
0.00%
Psychology visits (CBT)
100%
100%
0%
0.00%
Immunomodulating infusion
therapy – rituximab
0%
100%
100%
N/A
Immunomodulating infusion
therapy – IVIG session
0%
100%
100%
N/A
Plasma exchange
0%
100%
100%
N/A
Utilization and cost
Number of enrollees diagnosed
with PANDAS/PANS
670
670
—
0.00%
Annual utilization per enrollee
diagnosed with PANDAS/PANS:
Diagnostics (b)
210.0
210.0
—
0.00%
Oral prescription medications
(30-day supply) (c) (d)
17.8
17.8
—
0.00%
Psychology visits (CBT)
20.0
20.0
—
0.00%
Immunomodulating infusion
therapy – rituximab (e)
—
0.1
0.1
0.00%
Immunomodulating infusion
therapy – IVIG session (e)
—
0.7
0.7
0.00%
Plasma exchange session
(f)
(f)
—
0.00%
Average unit cost of the following
PANDAS/PANS-related services:
Diagnostics (b)
$30
$30
—
0.00%
Oral prescription medications
(30-day supply) (c) (d)
$7
$7
—
0.00%
Psychology visits (CBT)
$142
$142
—
0.00%
Immunomodulating infusion
therapy – rituximab
$9,566
$9,566
—
0.00%
Immunomodulating infusion
therapy – IVIG session
$4,312
$4,312
—
0.00%
Plasma exchange session
$2,136
$2,136
—
0.00%
Expenditures
Premiums
Employer-sponsored (g)
$57,647,993,000
$57,648,888,000
$895,000
0.002%
CalPERS employer (h)
$6,158,262,000
$6,158,345,000
$83,000
0.001%
Medi-Cal (excludes COHS) (i)
$29,618,383,000
$29,619,854,000
$1,471,000
0.005%
Enrollee premiums (expenditures)

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org x
Enrollees, individually purchased
insurance
$21,229,233,000
$21,229,347,000
$114,000
0.001%
Outside Covered California
$4,867,955,000
$4,868,000,000
$45,000
0.001%
Through Covered California
$16,361,278,000
$16,361,347,000
$69,000
0.000%
Enrollees, group insurance (j)
$18,263,775,000
$18,264,049,000
$274,000
0.002%
Enrollee out-of-pocket expenses
Cost sharing for covered benefits
(deductibles, copayments, etc.)
$13,857,141,000
$13,857,294,000
$153,000
0.001%
Expenses for noncovered benefits
(k) (l)
$0
$0
$0
0.00%
Total expenditures
$146,774,787,000
$146,777,777,000
$2,990,000
0.002%
Source: California Health Benefits Review Program, 2023.
Notes: (a) Enrollees in plans and policies regulated by DMHC or CDI. Includes those associated with Covered California, CalPERS,
or Medi-Cal.
5
(b) Diagnostics include various blood tests, throat cultures, and nose swabs. See Appendix C for more details. CHBRP estimates
that 15,410 enrollees ages 0-17 have diagnostic tests used as for PANDAS/PANS diagnosis each year. Of every 23 enrollees who
undergo diagnostic tests, CHBRP estimates that 1 enrollee is diagnosed with PANDAS/PANS, and 22 enrollees are not given this
diagnosis.
(c) Although mycophenolate mofetil is included in the PANDAS/PANS guidelines, we excluded it from our analysis based on
discussions with physicians in the field.
(d) Oral prescription medications include antibiotics, corticosteroids, nonsteroidal anti-inflammatory drugs, selective serotonin uptake
inhibitors, benzodiazepines, and antipsychotics. See Appendix C for more details.
(e) The percent changes postmandate for rituximab and IVIG are greater than zero, but appear to be zero in the table due to
rounding.
(f) Utilization for plasma exchange session is not projected to change due to a variety of supply issues, as discussed in the report.
(g) In some cases, a union or other organization. Excludes CalPERS.
(h) Includes only CalPERS enrollees in DMHC-regulated plans. Approximately 51.1% are state retirees, state employees, or their
dependents. About one in five of these enrollees has a pharmacy benefit not subject to DMHC.
6
CHBRP has projected no impact for
those enrollees. However, CalPERS could, postmandate, require equivalent coverage for all its members (which could increase the
total impact on CalPERS).
(i) Includes only Medi-Cal beneficiaries enrolled in DMHC-regulated plans. In addition, CHBRP is estimating that there would also be
a proportional increase of $0.37 million for Medi-Cal beneficiaries enrolled in COHS managed care.
(j) Enrollee premium expenditures include contributions by enrollees to employer (or union or other organization)-sponsored health
insurance, health insurance purchased through Covered California, and any contributions to enrollment through Medi-Cal to a
DMHC-regulated plan.
(k) Includes only expenses paid directly by enrollees (or other sources) to providers for services related to the mandated benefit that
are not covered by insurance at baseline. This only includes those expenses that will be newly covered postmandate. Other
components of expenditures in this table include all health care services covered by insurance.
(l) For covered benefits, such expenses would be eliminated, although enrollees with newly compliant benefit coverage might pay
some expenses if benefit coverage is denied (through utilization management review).
Key: CalPERS = California Public Employees’ Retirement System; CBT = cognitive behavioral therapy; CDI = California Department
of Insurance; COHS = County Organized Health Systems; DMHC = Department of Managed Health Care; IVIG = intravenous
immunoglobulin; PANDAS = Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections; PANS =
Pediatric Acute-onset Neuropsychiatric Syndrome.
5
For more detail, see CHBRP’s resource, Sources of Health Insurance in California, available at
http://chbrp.org/other_publications/index.php.
6
For more detail, see CHBRP’s resource, Pharmacy Benefit Coverage in State-Regulated Health Insurance,
available at http://chbrp.org/other_publications/index.php.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 1
POLICY CONTEXT
The California Assembly Committee on Health has requested that the California Health Benefits Review
Program (CHBRP)
7
conduct an evidence-based assessment of the medical, financial, and public health
impacts of AB 907, coverage of PANDAS and PANS, as amended on March 16, 2023.
Bill-Specific Analysis of AB 907, Coverage of PANDAS and PANS
Bill Language
AB 907, as amended on March 16, 2023, would require health plans regulated by the Department of
Managed Health Care (DMHC) and health policies regulated by the California Department of Insurance
(CDI) to provide coverage for the prophylaxis, diagnosis, and treatment of Pediatric Autoimmune
Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset
Neuropsychiatric Syndrome (PANS). Covered treatments must include antibiotics, medications and
behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma
exchange, and intravenous immunoglobulin (IVIG) therapy.
The bill also requires coverage to abide by the following terms and conditions:
• Prohibition on cost sharing being greater than that applied to other benefits provided by the
contract or policy.
• Coverage would be required to be provided in a timely manner. Denials or delays in coverage for
PANDAS or PANS therapies would be prohibited, if the denial or delay was because the enrollee
was diagnosed with, or previously received treatment for, a condition under a different diagnostic
name, including autoimmune encephalopathy.
• Prohibition on limitations to coverage for immunomodulating therapies for PANDAS/PANS in a
manner inconsistent with clinical practice guidelines and evidence-based standards for diagnosis
and treatment of PANDAS/PANS.
• Prohibition on a mandate for step therapy to treat only neuropsychiatric symptoms prior to
authorization of coverage for immunomodulating therapies.
• Coverage would be required to adhere to treatment recommendations developed by a consortium
of medical professionals convened to research, identify, and publish clinical practice guidelines
and evidence-based standards for the diagnosis and treatment of PANDAS and PANS.
AB 907 also requires PANDAS and PANS to be coded as autoimmune encephalitis for the purposes of
billing and diagnosis, until the American Medical Association and the federal Centers for Medicare and
Medicaid Services (CMS) create and assign a specific code for PANDAS and PANS. Once created, the
bill allows for PANDAS and PANS to be coded as either the specific codes or autoimmune encephalitis.
The full text of AB 907, as introduced, can be found in Appendix A.
Relevant Populations
If enacted, AB 907 would apply to the health insurance of approximately 22.8 million enrollees (58.6% of
all Californians). This represents all Californians who will have health insurance regulated by the state
that may be subject to any state health benefit mandate law, which includes health insurance regulated
7
CHBRP’s authorizing statute is available at www.chbrp.org/about_chbrp/faqs/index.php.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 2
by the DMHC or the CDI. If enacted, the law would apply to the health insurance of enrollees in DMHC-
regulated plans and CDI-regulated policies, including DMHC-regulated Medi-Cal plans.
As of January 1, 2022, outpatient prescription drugs are covered on a fee-for-service basis by the
California Department of Health Care Services (DHCS) for all Medi-Cal beneficiaries.
8
Their pharmacy
benefit is “carved out” of the coverage provided by Medi-Cal managed care plans, and so AB 907 would
not be expected to impact their outpatient prescription drug benefit coverage.
Analytic Approach and Key Assumptions
CHBRP used the guidelines developed by the PANDAS Physicians Network (PPN), the PANDAS/PANS
Clinical Research Consortium, and Nordic Pediatric Immunopsychiatry Group in its analytic approach to
AB 907 (Chang et al., 2015; Cooperstock et al., 2017; Frankovich et al., 2017; Pfeiffer et al., 2021;
Thienemann et al., 2017). More information is provided in the Background on PANDAS and PANS
section. CHBRP’s analysis uses these guidelines to support its analytic approach but notes that revisions
or future guidelines may differ from those used for this analysis. Table 2 shows the treatments required by
AB 907 and those included in the guidelines mentioned above.
It should be noted that the language of AB 907 requires coverage of PANDAS and PANS to adhere to
treatment recommendations in clinical practice guidelines and evidence-based standards; the guidelines
developed by the aforementioned groups are consensus guidelines. Evidence-based guidelines make
statements that are informed by a systematic review of the evidence and an assessment of the benefits
and harms of alternative options. Consensus guidelines are developed by an independent panel of
experts with experience in the condition(s), usually multidisciplinary, convened to review the research
literature in an evidence-based manner for the purpose of advancing the understanding of an issue,
procedure or method (Jacobs et al, 2014). The key difference between the development of the two types
of guidelines appears to be that when the evidence is of high quality, some guideline panels rely on the
evidence review to guide their recommendations and the process is evidence-based. However, when the
evidence is very limited and hence of low quality or very low quality, some guideline panels rely primarily
on clinical experience and the process is consensus-based (Yao et al, 2021).
Table 2 also shows whether the treatments under AB 907 would fall under the medical or pharmacy
benefit. Drugs that are physician-ordered and administered under the supervision of a physician –
generally in a hospital, a provider’s office, infusion center, or similar medical facility – along with the
hospital stay or office visit are generally covered through a medical benefit. The intravenous
immunomodulating therapies discussed in this analysis would fall into this category and are assumed to
be covered under the medical benefit. Pharmacy benefits cover outpatient prescription drugs by covering
prescriptions that are generally filled at a retail pharmacy, a mail-order pharmacy, or a specialty
pharmacy.
Table 2. Treatments Considered for AB 907 Analysis
Treatment Required by AB 907
Medications/Treatment From Clinical
Guidelines
Benefit Type
Antibiotics
Azithromycin, penicillin
Pharmacy
Behavioral therapies to manage
neuropsychiatric symptoms
Cognitive behavioral therapy
Medical
8
For more on outpatient prescription drug coverage among Californians with state-regulated health insurance, see
CHBRP’s resource, Pharmacy Benefit Coverage in State-Regulated Health Insurance, available at
https://chbrp.org/other_publications/index.php.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 3
Oral prescription medications to
manage neuropsychiatric symptoms
Psychotropics (i.e., selective serotonin reuptake
inhibitors, benzodiazepines, antipsychotics)
Pharmacy
Immunomodulating therapies
Intravenous
Intravenous immunoglobulin therapy, plasma
exchange, rituximab
Medical
Oral medications
Corticosteroids, nonsteroidal anti-inflammatory
drugs, mycophenolate mofetil, vitamin D
Pharmacy
Source: California Health Benefits Review Program, 2023.
Key: CBT = cognitive behavioral therapy; IVIG = intravenous immunoglobulin therapy; NSAIDS = nonsteroidal anti-inflammatory
drugs.
CHBRP uses the age range of 0 to 17 years throughout this analysis because the diagnostic criteria for
PANDAS and PANS include pediatric onset (Chang et al, 2013; NIMH, 2019). However, CHBRP
recognizes that people over the age of 17 may also present symptoms similar to those of PANDAS and
PANS or have an initial diagnosis of either syndrome at a pediatric age that continues into adulthood.
CHBRP assumed that if AB 907 was enacted, cost sharing for treatments outlined in the bill would not
change and that DMHC-regulated plans and CDI-regulated policies would require prior authorization for
some treatments.
The California Department of Health Care Services (DHCS) began implementation of the California
Advancing and Innovating Medi-Cal (CalAIM) initiative in 2022. To the extent possible for this analysis,
CHBRP has incorporated known CalAIM changes into its methods and approach.
Interaction With Existing State and Federal Requirements
Health benefit mandates may interact and align with the following state and federal mandates or
provisions.
California Policy Landscape
California law and regulations
The California Legislature has not previously introduced mandates related to PANDAS or PANS. In 2018,
California passed a resolution proclaiming October 9 as PANS awareness day.
CHBRP reviewed the state’s Independent Medical Review (IMR) determinations since the implementation
of the Affordable Care Act (ACA) in California and found 29 related to coverage of treatment for PANDAS,
PANs, and autoimmune encephalitis. All determinations were specific to coverage of IVIG. A total of 15
IMRs overturned the decision of the health plan for enrollees requesting coverage for IVIG, based on the
refractory nature of the patient’s condition and sufficient evidence showing lack of improvement following
first-line therapies. The health plans’ decisions were upheld in 14 instances where enrollees requested
coverage of IVIG either due to insufficient medical evidence and/or lack of clinical evidence supporting
the patient’s diagnosis and therefore medical necessity
9
for the treatment. CHBRP found 5 determinations
specific to the diagnosis of PANDAS and PANS. None of the medical reviews were for coverage requests
of diagnostic tests or services recommended by any of the guidelines used by CHBRP for this analysis.
9
A medically necessary treatment or service is one that is appropriate and consistent with a patient's diagnosis and
that, in accordance with locally accepted standards of practice, cannot be omitted without adversely affecting the
patient's condition or quality of care.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 4
Similar requirements in other states
There are 10 states, including Arkansas, Delaware, Illinois, Indiana, Kansas, Maryland, Massachusetts,
Minnesota, New Hampshire, and Rhode Island, that mandate at least temporary coverage of treatment
for PANDAS and PANS. Arkansas mandates health plans cover the off-label use
10
of drug treatment to
treat PANS and PANDAS, but allows for cost sharing and prior authorization requirements.
11
Delaware,
Illinois, Indiana, and Maryland mandate coverage but only specify that IVIG must be covered.
12
Massachusetts also only specifies IVIG must be covered, and sets up an advisory council on PANDAS
and PANS.
13
Kansas, New Hampshire, and Rhode Island allow for temporary coverage of treatment for
PANDAS and PANS until December 31, 2023; July 1, 2024; and December 31, 2025, respectively.
Minnesota’s law is most similar to AB 907, describing the same set of treatments that may be
recommended by a health care professional for PANDAS and PANS.
14
This year, 12 states in addition to California (Arkansas, Connecticut, Georgia, Illinois, Maine,
Massachusetts, Missouri, New York, Oregon, Rhode Island, Texas, and West Virginia) have introduced
legislation this year related to PANDAS and PANS. Arkansas’ and Illinois’ legislation would amend their
existing laws to specify conditions under which IVIG and other treatment coverage must be provided.
15
Rhode Island’s legislation would have extended the sunset for coverage for treatment but was held for
further study.
16
Massachusetts’ bill would order a study to be conducted related to PANDAS and PANs in
conjunction with its PANS advisory council.
17
Georgia’s legislation would establish a 3-year pilot program
to provide coverage for the diagnosis and treatment of PANDAS and PANS, beginning in 2025.
18
The
Missouri and Oregon bills would specify coverage for IVIG treatments, and Maine’s bill would provide
coverage for the similar treatments as those mandated in AB 907.
19
New York and Connecticut’s
legislation would mandate coverage for unspecified treatment of PANS.
20
Texas’ bill would establish
PANS advisory council.
21
West Virginia’s legislation mandates coverage for IVIG for PANDAS and PANS
and other autoimmune encephalopathies only if prior authorization is obtained by showing all other
treatments have been exhausted.
22
Federal Policy Landscape
Affordable Care Act
A number of Affordable Care Act (ACA) provisions have the potential to or do interact with state benefit
mandates. Below is an analysis of how AB 907 may interact with requirements of the ACA as presently
10
The term off-label refers to use of a drug in a way that differs from the specifications explicitly approved by the
Food and Drug Administration (FDA). Off-label use of drugs is not uncommon and is discussed by the FDA on a
webpage intended for patients. See www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-
options/understanding-unapproved-use-approved-drugs-label. Accessed March 13, 2023. The FDA’s specifications
may include particular drug dosages (a measurement, often in milligrams) or particular dosage forms (oral vs.
inhaled, extended vs. immediate release, ocular vs. oral, etc.).
11
Arkansas Code Annotated § 23-79-1905.
12
Delaware 18 §3370B & 3571T; 215 Illinois Insurance Code 5/356z.25; Indiana §27-8-37-1; Maryland Insurance
Code 15-855.
13
Massachusetts General Laws 176G §4GG, 175 §47NN, 176B §400, 32A §17R, 176A §800, 111 §242.
14
Minnesota Code §62A.3097.
15
Arkansas Senate Bill (SB) 181; Illinois SB 101.
16
Rhode Island SB 0024 and House Bill (HB) 5256.
17
Massachusetts SB 1266.
18
Georgia House Bill 140.
19
Oregon SB 628; Missouri HB 1365; Maine HB 663.
20
New York SB 3038 and Assembly Bill 2823; Connecticut SB 452.
21
Texas HB 3808 and SB 1185.
22
West Virginia SB 45.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 5
exist in federal law, including the requirement for certain health insurance to cover essential health
benefits (EHBs).
23
,
24
Essential Health Benefits
In California, nongrandfathered
25
individual and small-group health insurance is generally required to
cover essential health benefits (EHBs).
26
In 2024, approximately 12.1% of all Californians will be enrolled
in a plan or policy that must cover EHBs.
27
States may require state-regulated health insurance to offer benefits that exceed EHBs.
28
,
29
,
30
Should
California do so, the state could be required to defray the cost of additionally mandated benefits for
enrollees in health plans or policies purchased through Covered California, the state’s health insurance
marketplace. However, state benefit mandates specifying provider types, cost sharing, or other details of
existing benefit coverage would not meet the definition of state benefit mandates that could exceed
EHBs.
31
,
32
AB 907 would not require coverage for a new state benefit mandate that appears to exceed the definition
of EHBs in California.
23
The ACA requires nongrandfathered small-group and individual market health insurance – including, but not limited
to, qualified health plans sold in Covered California – to cover 10 specified categories of EHBs. Policy and issue
briefs on EHBs and other ACA impacts are available on the CHBRP website:
www.chbrp.org/other_publications/index.php.
24
Although many provisions of the ACA have been codified in California law, the ACA was established by the federal
government, and therefore, CHBRP generally discusses the ACA as a federal law.
25
A grandfathered health plan is “a group health plan that was created – or an individual health insurance policy that
was purchased – on or before March 23, 2010. Plans or policies may lose their ‘grandfathered’ status if they make
certain significant changes that reduce benefits or increase costs to consumers.” Available at:
www.healthcare.gov/glossary/grandfathered-health-plan.
26
For more detail, see CHBRP’s issue brief, California State Benefit Mandates and the Affordable Care Act’s
Essential Health Benefits, available at https://chbrp.org/other_publications/index.php.
27
See CHBRP’s resource, Sources of Health Insurance in California and CHBRP’s issue brief California State Benefit
Mandates and the Affordable Care Act’s Essential Health Benefits, both available at
https://chbrp.org/other_publications/index.php.
28
ACA Section 1311(d)(3).
29
State benefit mandates enacted on or before December 31, 2011, may be included in a state’s EHBs, according to
the U.S. Department of Health and Human Services (HHS). Patient Protection and Affordable Care Act; Standards
Related to Essential Health Benefits, Actuarial Value, and Accreditation. Final Rule. Federal Register, Vol. 78, No. 37.
February 25, 2013. Available at: www.gpo.gov/fdsys/pkg/FR-2013-02-25/pdf/2013-04084.pdf.
30
However, as laid out in the Final Rule on EHBs U.S. Department of Health and Human Services (HHS) released in
February 2013, state benefit mandates enacted on or before December 31, 2011, would be included in the state’s
EHBs, and there would be no requirement that the state defray the costs of those state-mandated benefits. For state
benefit mandates enacted after December 31, 2011, that are identified as exceeding EHBs, the state would be
required to defray the cost.
31
Essential Health Benefits. Final Rule. A state’s health insurance marketplace would be responsible for determining
when a state benefit mandate exceeds EHBs, and qualified health plan issuers would be responsible for calculating
the cost that must be defrayed. Patient Protection and Affordable Care Act; Standards Related to Essential Health
Benefits, Actuarial Value, and Accreditation. Final Rule. Federal Register, Vol. 78, No. 37. February 25, 2013.
Available at: www.gpo.gov/fdsys/pkg/FR-2013-02-25/pdf/2013-04084.pdf.
32
Both Massachusetts and Utah currently pay defrayment costs for exceeding EHBs (Maine Bureau of Insurance,
2023).

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 6
BACKGROUND ON PANDAS AND PANS
AB 907 would require Department of Managed Health Care (DMHC)-regulated health plans and
California Department of Insurance (CDI)-regulated policies to provide coverage for the prophylaxis,
diagnosis, and treatment of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal
Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). The treatments covered
under this bill would include:
• Antibiotics;
• Medications and behavioral therapies to manage neuropsychiatric symptoms;
• Immunomodulating medicines;
• Plasma exchange; and
• Intravenous immunoglobulin therapy (IVIG).
This section explains the terms PANDAS and PANS, provides an overview of the diagnostic criteria and
treatments based on available clinical practice guidelines, and describes the prevalence and incidence of
the disease in California.
What Are PANS and PANDAS?
Identified in the published peer-reviewed literature in 1998, PANDAS/PANS are terms used to describe a
subset of children with symptoms that include a sudden onset of a collection of neuropsychiatric
symptoms co-occurring with obsessive-compulsive disorder (OCD) and/or tic disorders usually following
an infection (NIMH, 2019; Pichichero et al., 2023; PPN, 2023c).
PANDAS, currently classified as a subset of PANS, is hypothesized by some to be triggered by an
autoimmune response to Group A Streptococcal (Strep) bacteria (which cause strep throat or soft tissue
infections). More specifically, some research hypothesizes that the body’s immune system may produce
antibodies (known as cross-reactive antibodies) that create a dysfunctional autoimmune response
following a Group A Strep infection, which may result in a range of conditions, including rheumatic fever
which affects the heart valves. These cross-reactive antibodies may occur in the brain, where the
autoimmune response is thought to result in sudden onset of neuropsychiatric symptoms such as OCD,
tic disorders, and other psychiatric symptoms that also present in children diagnosed with PANDAS
(NIMH, 2019). However, findings from other studies run counter to this hypothesis. Two prospective,
blinded case-control studies have shown no observable temporal relationship between Group A Strep
infection and the clinical exacerbations (i.e., worsening or increase in symptoms) associated with patients
who met published diagnostic criteria for PANDAS (Kurlan et al., 2008; Leckman et al., 2011).
PANS is hypothesized to be triggered by causes other than Group A Streptococcus infection (Calaprice et
al., 2017; NIMH, 2019; PPN, 2023c).
Much remains unknown about PANDAS and PANS and controversy remains regarding whether PANDAS
differs enough from pediatric OCD or tic disorders and other neuropsychiatric disorders to warrant a
different diagnostic category (Kronenberg and Shouldice, 2019; Pichichero et al. 2023). The body of
research related to PANDAS and PANS is small (number of studies and sample sizes among studies)
compared with many other diseases and conditions (see the Medical Effectiveness section).

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 7
Symptoms
Both PANDAS and PANS are characterized by a child experiencing sudden onset or significant
worsening of OCD
33
and/or tic disorders
34
along with at least two additional physical or neuropsychiatric
symptoms (Pichichero et al, 2023). OCD symptoms associated with PANDAS may be more abrupt and
more extreme than the symptoms of a child diagnosed solely with typical OCD (NIMH, 2019; Rosenberg
et al., 2022). Children may also become moody or irritable, or experience anxiety attacks, separation
anxiety, rage, fatigue, phobias, insomnia, joint or muscle pain, or eating disorders. Figure 1 describes the
intersection and differences between common symptoms for PANDAS/PANS.
Figure 1. Common Symptoms of PANDAS/PANS Used for Clinical Diagnosis
Source: CHBRP, 2023. Based on Godlewski et al., 2021; NIMH, 2019; PPN, 2023c.
Key: ADHD = attention-deficit/hyperactivity disorder; OCD = obsessive-compulsive disorder; PANDAS = Pediatric Autoimmune
Neuropsychiatric Disorder Associated with Streptococcal Infections; PANS = Pediatric Acute-onset Neuropsychiatric Syndrome.
The PANDAS Physicians Network
35
(PPN, 2023b) classifies cases as:
• Mild: Symptoms are significant and last a few hours per day and cause disruptions at home,
school or in the community.
33
OCD includes obsessive thoughts and compulsive behaviors used in an attempt to rid a person of their
uncontrolled and distressing thoughts, images, or impulses that occur repeatedly. Examples include obsessions with
germs, responsibility, death, identity, or religious/moral ideas. Compulsions are exhibited through repetitive behaviors
to neutralize the thoughts such as washing hands or cleaning in a specific way, repeating simple actions such as
exiting/entering a door, counting, or repeating body movements such as tapping or blinking (IOF, 2023).
34
Tic disorders include Tourette Syndrome and Persistent Tic Disorder. Tics are involuntary, sudden, repetitive
physical movements (e.g., blinking) and vocal sounds (e.g., grunting, yelling a certain word) that occur many times a
day, nearly daily for more than a year (CDC, 2023).
35
PANDAS Physicians Network is a clinician-oriented organization that created PPN Guidelines for Diagnostics and
Therapeutics, provides education and communication to the medical community, and sponsors research for
developing diagnostic tests, treatment protocols and a cure for PANDAS/PANS.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 8
• Moderate: Symptoms are distressing and interfere with daily activities. Symptoms occur about
50% to 70% of waking hours.
• Severe: Symptoms are incapacitating, life threatening, or occupy 71% to 100% of waking hours.
The severity and frequency of symptoms for those diagnosed with PANDAS or PANS can range from a
single event with milder and/or fewer symptoms that resolve within weeks to months, to a moderate level
that follows a remitting–relapsing pattern of moderate and/or more severe symptoms over multiple
months or years, to a multiyear course with severely disruptive, unmanaged symptoms. Milder cases may
resolve on their own without treatment, whereas other types of cases may respond to medication and
cognitive behavioral therapy (CBT) treatments such that symptoms completely resolve or are reduced
and become more manageable (Godlewski, et al., 2021; PPN, 2023c).
Prevalence of PANDAS/PANS in the United States
PANDAS/PANS has been primarily described in children between the ages of 3 and 12 years; however,
the exact prevalence and age distribution of PANDAS/PANS is unknown. Because OCD is a required
symptom for the diagnosis of PANDAS and PANS, it is thought their prevalence can be estimated as a
subset of the prevalence of pediatric OCD. Epidemiological research estimates that 0.5% to 5% of
children in the United States are affected by OCD (Nazeer et al., 2020; Rosenberg et al., 2022).
In a study of 136 youth with a lifetime diagnosis of OCD, Jaspers-Fayer at al. (2017) estimate that 5% of
children with OCD may meet the criteria for PANDAS/PANS, which translates to about 1 PANDAS/PANS
case/10,000 children (Jaspers-Fayer et al., 2017). Based on the statewide population of ~7.6 million
California children aged 3 to 17 years (KidsData, 2023), CHBRP estimates that fewer than 1,000
California children would be diagnosed with PANDAS/PANS at any time (regardless of insurance status);
note this estimate is based on a single study of 136 children with OCD (Jaspers-Fayer et al., 2017).
Research has found that the average age of onset of pediatric OCD ranges from 7.5 to 12.5 years and
that more males than females are diagnosed with the disorder (Godlewski et al., 2021). A survey of
patients diagnosed with PANS and parents/legal guardians of patients diagnosed with PANS found the
average age of onset of PANS symptoms was around 7.5 years old, but the average age of diagnosis
was 9.5 years (similar to that of OCD onset). This survey also found that males comprised 64% of
patients and on average were significantly younger than female patients (Calaprice et al., 2017).
Clinical Practice Guidelines
CHBRP found clinical practice guidelines from three different organizations; all recognize the syndromes’
range of severity (mild, moderate, severe) and recommend similar, but not perfectly aligned, treatments.
PANDAS/PANS Clinical Research Consortium
The PANDAS/PANS Clinical Research Consortium, developed out of the 2013 PANS Consensus
Conference,
36
describes consensus-based treatment options based on severity (mild, moderate-to-
severe, and extreme/life-threatening) and symptoms. The group recommended a three-pronged approach
to treat underlying infection and inflammation concurrent with treatment of psychiatric and behavioral
symptoms. PANS: Part I: Psychiatric and Behavioral Interventions identifies psychoactive medications,
psychotherapies (particularly cognitive behavioral therapy), and supportive interventions to treat
neuropsychiatric symptoms (Thienemann et al., 2017); Part II: Immunomodulatory Therapies
36
The PANS Consensus Conference convened researchers and clinicians with clinical interest in PANS/PANDAS in
May 2013 at Stanford University. The group consisted of clinicians and researchers specializing in several fields of
pediatrics with the goals of clarifying the diagnosis of PANS, developing strategies to evaluate suspected PANS
cases and to determine research priorities in the field (Chang et al., 2015).

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 9
recommends immunomodulatory and/or anti-inflammatory therapies to treat disturbances of the immune
system (based on symptom severity and disease trajectory) (Frankovich et al., 2017); and Part III:
Antimicrobial Interventions recommends treatments for infection to remove the source of inflammation
(Cooperstock et al., 2017). The guidelines also recommend that clinicians frequently evaluate the
effectiveness of the patient’s treatments and adjust according to symptom response.
PANDAS Physician Network
The Guidelines and Therapeutics Committee of the PANDAS Physician Network developed diagnostic
guidelines and treatment guidelines for children with PANDAS/PANS based on recommendations from
the 2013 PANS Consensus Conference, PANDAS/PANS Clinical Research Consortium, and ongoing
research and clinical experience (PANDAS, 2020). Diagnostic and treatment guidelines for both PANS
and PANDAS are categorized by three severity levels: mild, moderate, and severe. Recommended initial
treatments for mild cases include use of antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and
CBT. For moderate/severe cases, the recommended initial treatment is to consider a longer course of
antibiotics, referral to a psychiatrist to help manage symptoms. For severe cases, prescribing high-dose
intravenous and/or prolonged steroid treatment with a taper, or at least one round of IVIG treatment
should be considered. Patients should be assessed at follow-up visits to see whether symptoms have
improved or worsened, to determine whether treatment should be modified (such as restarting or
changing antibiotics, prescribing prednisone or NSAIDs if not already tried), and to consider a possible
alternative diagnosis. For severe to extreme cases unresponsive to the treatments listed above or with
worsening symptoms, plasma exchange, rituximab infusions, or mycophenolate mofetil should be
considered (Chang et al., 2015; Swedo et al., 2012).
Nordic Pediatric Immunopsychiatry Group
A group of pediatric neurologists, child psychologists, and child psychiatrists from Nordic countries
developed clinical guidance on the diagnosis and management of PANS. The general treatment
approach is to 1) treat mental health symptoms; 2) treat ongoing verified infections; and 3) treat
suspected inflammation. Specific treatments outlined in the guidelines are antibiotics, NSAIDs, steroids,
and IVIG (Pfeiffer et al., 2021). The group adopted clinical and diagnostic criteria consistent with
recommendations by PANS/PANDAS experts in the United States (Chang et al., 2015; Swedo et al.,
2012), but also proposed criteria for defining severe cases of PANS/PANDAS. Similar to the other
guidelines, the Nordic group recommended antibiotics and NSAIDs for initial treatment, and to consider
steroids and IVIG for more severe cases. However, the Nordic group did not recommend the use of
rituximab for treatment (Pfeiffer et al., 2021).
PANDAS/PANS Diagnosis and Treatment Path
PANDAS/PANS is uncommon and despite the first publication on the topic occurring in 1998, it remains
unfamiliar to much of the clinical community (Swedo et al., 1998). Clinicians commonly involved in
diagnosing PANDAS/PANS may include a family physician, pediatrician, pediatric nurse practitioner,
pediatric neurologist, pediatric psychiatrist, neurodevelopmental pediatrician, pediatric rheumatologist,
and pediatric allergist/immunologist. Despite the wide variety of clinicians listed, many are unfamiliar with
the syndromes and how to diagnose or treat them. There are ~10 PANDAS/PANS clinics nationwide with
2 located in California (Stanford and UCLA) (PPN, 2023a).
Diagnosis
Due to the lack of diagnostic laboratory or imaging tests specific to PANDAS/PANS,
37
and the overlap of
symptoms with multiple conditions, the diagnostic process for these syndromes is challenging. The
37
PANS has no specific diagnostic or billing codes; an ICD-10 code for PANDAS exists, as noted later in this section.
AB 907 would require the use of the codes for autoimmune encephalitis (AE) until national billing codes for

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 10
PANDAS/PANS diagnostic process relies primarily on a clinical diagnosis in conjunction with laboratory
testing to rule out conditions with similar symptoms such as pediatric autoimmune encephalitis, other
pediatric infection-triggered autoimmune neuropsychiatric disorders (e.g., childhood acute
neuropsychiatric syndromes (CANS), Sydenham chorea, neuropsychiatric lupus, etc.), Tourette
syndrome, pediatric OCD, Tumor Necrosis Factor Receptor Associated Periodic Syndrome, and central
nervous system vasculitis (Baj et al., 2020; Godlewski et al., 2021; Hutanu et al., 2022). Misdiagnosis and
children’s suppression of behaviors during diagnostic visits also make accurate diagnosis challenging.
The clinical diagnosis focuses on a detailed medical history to define sudden onset, possible relation to
recent infections, and documentation of current symptoms (Figure 1). To explore the possibility of a
recent, unidentified strep infection, the clinician will perform a throat swab culture to check for Group A
beta hemolytic strep (GABHS) (NIMH, 2019). Antibodies to GABHS can be detected in a blood test,
indicating a prior infection, but a high anti-strep antibody titer result is not a definitive diagnosis alone for
PANDAS. Other tests may include blood tests to diagnose other autoimmune conditions or infections,
neuroimaging (e.g., magnetic resonance imaging [MRI]), electroencephalogram (EEG), and cerebral
spinal fluid testing.
As discussed in the Policy Context section, the language of AB 907 specifies that for billing and
diagnostic purposes, PANDAS and PANS must be coded as autoimmune encephalitis until the American
Medical Association and the federal Centers for Medicare and Medicaid Services create and assign a
specific code or codes for PANDAS and PANS. As of the published date of this report, an ICD-10 code
exists for PANDAS as D89.89, which is used for “other specified disorders involving the immune
mechanism, not elsewhere classified.” There is no ICD-10 code associated with PANS.
Treatment of PANDAS/PANS
Based on the clinical guidelines discussed in the previous subsection, treatment options for
PANDAS/PANS depend on the physical and/or neuropsychiatric symptoms experienced by the patient.
Treatments recommended by consensus guidelines will vary according to patient case severity and
symptomology (see the Medical Effectiveness section for discussion of potential side effects and harms).
Antibiotics: Penicillin, azithromycin, or other types of antibiotics may be prescribed to eliminate a
bacterial infection such as Streptococcus A.
Nonsteroidal Anti-inflammatory Drugs (NSAIDS): Nonsteroidal anti-inflammatory drugs, such as
ibuprofen or naproxen, treat pain, fever, and reduce inflammation.
Corticosteroids: Steroids are prescribed for their anti-inflammatory and immunosuppressive effects.
Cognitive Behavioral Therapy (CBT): This therapy focuses on changing thinking patterns (gaining a
better understanding of the behavior and motivation of others and using problem-solving skills to cope
with difficult situations) and changing behavioral patterns (role playing to prepare for potentially
problematic interactions with others and learning to how to calm the mind and body). It can be used to
treat depression, anxiety disorders, OCD, eating disorders, and severe mental illness (APA, 2017).
Psychotropics: This large class of medications includes antidepressants (including selective serotonin
reuptake inhibitors [SSRIs]), anti-anxiety medications (e.g., benzodiazepines), stimulants, and
antipsychotics that are used to manage symptoms of depression, anxiety, attention deficit disorder,
insomnia, and OCD or eating disorders.
Intravenous immunoglobulin (IVIG): This blood-plasma-derived product is Food and Drug
administration (FDA)-approved to treat a handful of diseases but has seen growing demand for off-label
PANS/PANDAS become available. The symptoms of AE are closely aligned with those of PANS/PANDAS; however,
there are more diagnostic tests available to identify AE than PANS/PANDAS (Barbagallo, et al., 2017).

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use
38
to treat autoimmune disorders and neurological diseases. It is part of the immunomodulator family
39
that suppresses or enhances immune responses through the delivery of human antibodies intravenously
in a clinic setting (Ballow and Shehata, 2023). National shortages have been documented due to plasma
collection shortages and lengthy, complex manufacturing processes (FDA, 2022; Rhodes, 2021).
Published strategies for optimizing limited supplies for patients include lowering doses, delaying
treatments, prioritizing based on medical need, and using alternative therapies when those exist (Rhodes,
2021).
B-cell modulator (rituximab): Rituximab is an immunoglobulin G1 monoclonal antibody used to treat
rheumatoid arthritis, non-Hodgkin lymphoma, and chronic lymphocytic leukemia. Similar to IVIG, it is
administered intravenously in a clinic setting.
Therapeutic plasma exchange: This process uses a machine to remove patient plasma and separate
the blood into its components. It discards the unwanted cells or plasma into a discard container and
returns most of the remaining blood to the patient along with replacement fluids and a short-acting
anticoagulant, usually citrate (Kaplan and Fridey, 2022).
Mycophenolate mofetil: An immunosuppressant drug FDA-approved for use by organ transplant
patients to prevent organ rejection. It is also used to treat autoimmune diseases such as lupus,
rheumatoid arthritis and Crohn’s disease (American College of Rheumatology, 2023).
Barriers to Accessing Diagnosis and Treatment of PANDAS/PANS
Barriers for the diagnosis and treatment of PANDAS/PANS include the lack of evidence on effective
treatment options. The lack of clinicians familiar with PANDAS and PANS contributes to long distance
travel (and associated travel expenses) for families seeking care (O’Dor et al., 2022; Tang et al., 2021).
PANDAS/PANS symptoms overlap with symptoms of other conditions, thus the lack of a definitive test
and reliance on a differential diagnosis can lead to delayed diagnosis. Misdiagnosis, and children’s
suppression of behaviors during assessments are also treatment barriers in PANDAS/PANS (O'Dor et al.,
2022; Tang et al., 2021). Treatment for moderate-to-severe PANDAS/PANS generally requires pediatric
specialists, and ideally, coordinated care among treating clinicians who may be in different care settings.
For patients with mild or moderate cases, weekly therapy with CBT, or outpatient daily therapy may be
prescribed, but due to pediatric behavioral health workforce shortages in California (Coffman et al., 2018),
both may be difficult to access. For patients with more severe cases, space in inpatient day programs or
hospitalizations, where treatment may last from 1 week to months, may be difficult to obtain due to
California’s shortage of pediatric psychiatric care clinicians and inpatient and treatment beds (AACAP,
2023; Weiner, 2021).
Disparities
40
in PANDAS/PANS
CHBRP found no literature identifying disparities regarding PANDAS/PANS.
38
Off-label use refers to an FDA-approved medication used to treat a condition or symptom that is not approved by
the FDA. According to the FDA, once a drug is approved, “healthcare providers generally may prescribe the drug for
an unapproved use when they judge that it is medically appropriate for their patient.” (FDA, 2018). It is common
practice among clinicians to prescribe medications off-label.
39
Other immunomodulators include corticosteroids and NSAIDs.
40
Several competing definitions of “health disparities” exist. CHBRP relies on the following definition: Health disparity
is defined as the differences, whether unjust or not, in health status or outcomes within a population (Wyatt et al.,
2016).

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Quality of Life
The symptoms associated with PANS/PANDAS can negatively affect family and child quality of life
including community and social participation, activities of daily living, and education, and require
substantial changes to work and family life routines (Demchick et al., 2019).
Frankovich et al. (2018) measured the longitudinal caregiving burden of children diagnosed with
PANDAS/PANS who were treated at the Stanford PANS clinic. During first flares, caregiver burden for
half of the study respondents (48 of 97 respondents) was high enough to indicate an increased need for
respite care, scoring above similar studies of caregivers of Alzheimer’s patients. Over a three-year follow-
up, Frankovich et al. reported an overall reduction in caregiver burden regardless of continued affiliation
with the clinic. The study reported that delays in treatment initiation did not affect the rate of change in
caregiver burden.

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MEDICAL EFFECTIVENESS
As discussed in the Policy Context section, AB 907, as amended March 16, 2023, would mandate
coverage of prophylaxis, diagnosis, and certain treatments for Pediatric Autoimmune Neuropsychiatric
Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric
Syndrome (PANS). The treatments covered under this bill would include the following:
• Antibiotics;
• Medication and behavioral therapies to manage neuropsychiatric symptoms;
• Immunomodulating medicines;
• Plasma exchange; and
• Intravenous immunoglobulin therapy (IVIG).
The medical effectiveness review summarizes findings from evidence
41
on these treatments and their
effectiveness in reducing or eliminating symptoms of PANDAS/PANS. Symptoms are broad and differ by
case, however the most common symptoms include obsessive-compulsive disorder (OCD), tics, and
eating restrictions. Additional information on these treatments and syndromes are included in the
Background on PANDAS and PANS section.
Research Approach and Methods
CHBRP relied on a systematic review on treatment of PANDAS/PANS published in 2018 for findings from
studies published prior to 2017 (Sigra et al., 2018). For the period 2017 and following, CHBRP conducted
a supplemental review of abstracts of studies published in English from 2017 to present. This
supplemental review yielded 129 articles as candidates for the analysis.
Of the 129 articles found in the supplemental literature review, 14 were considered for full text review, of
which two were ultimately included for the medical effectiveness review. Combined with the nine studies
identified between two systematic reviews (Johnson et al., 2021; Sigra et al., 2018), a total of 11 studies
were included in the medical effectiveness review.
CHBRP found research available for PANDAS and PANS to be very limited; studies, when available,
were sparse and conducted with very small sample sizes. Because of the very limited evidence, a few
observational studies lacking comparison groups were included when no rigorous evidence was
available. Of note, eight of the nine studies from the systematic reviews were assessed to have a high or
moderate risk of bias.
The other articles were eliminated because they did not focus on pediatric patients diagnosed with
PANDAS/PANS, were of poor quality, or did not report findings from clinical research studies. A more
thorough description of the methods used to conduct the medical effectiveness review and the process
used to grade the evidence for each outcome measure is presented in Appendix B.
The conclusions below are based on the best available evidence from peer-reviewed and grey
literature.
42
Unpublished studies are not reviewed because the results of such studies, if they exist,
cannot be obtained within the 60-day timeframe for CHBRP reports.
41
Much of the discussion in this section is focused on reviews of available literature. However, as noted in the section
on Implementing the Hierarchy of Evidence in the Medical Effectiveness Analysis and Research Approach document
(posted at www.chbrp.org/about/analysis-methodology/medical-effectiveness-analysis in the absence of fully
applicable to the analysis peer-reviewed literature on well-designed randomized controlled trials (RCTs), CHBRP’s
hierarchy of evidence allows for the inclusion of other evidence.
42
Grey literature consists of material that is not published commercially or indexed systematically in bibliographic
databases. For more information on CHBRP’s use of grey literature, visit www.chbrp.org/about/analysis-
methodology/medical-effectiveness-analysis.

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Key Questions
1. For children experiencing PANDAS/PANS, what is the effectiveness of antibiotics in reducing or
eliminating symptoms? What are the harms?
2. For children experiencing PANDAS/PANS, what is the effectiveness of behavioral therapies and
psychotropic medications in reducing or eliminating symptoms? What are the harms?
3. For children experiencing PANDAS/PANS, what is the effectiveness of immunomodulating
treatments (e.g., NSAIDs, corticosteroids, IVIG, plasma exchange, rituximab, mycophenolate
mofetil, and vitamin D) in reducing or eliminating symptoms? What are the harms?
Methodological Considerations
As described in the Background on PANDAS and PANS section, PANDAS and PANS are both rare
syndromes with an episodic course, in which patients may experience a broad range of symptoms with
varying levels of severity.
There is no specific diagnostic test to confirm a diagnosis for PANDAS or PANS, and other conditions
may present with similar symptoms, making it a difficult to reliably diagnose and study PANDAS/PANS.
Clinicians use a differential diagnostic process that may include collecting a patient’s medical history or
conducting blood tests to rule out other conditions that may cause similar symptoms. Additional tests may
include testing for Group A Streptococcus, or Mycoplasma pneumoniae – infections that may be
associated with PANDAS or PANS (Chang et al., 2015; Pfeiffer et al., 2021b). The evidence for the use of
tests for diagnosis of other conditions or for PANDAS/PANS associated infections is beyond the scope of
what CHBRP is able to review within the legislative timeline.
As described in the Policy Context section, AB 907 would require that “coverage for PANDAS and PANS
shall adhere to the treatment recommendations developed by a consortium of medical professionals
convened to research, identify, and publish clinical practice guidelines and evidence-based standards for
the diagnosis and treatment of those disorders.” CHBRP identified 3 clinical practice guidelines that meet
the above criteria for diagnosing and treating patients with PANDAS/PANS (Chang et al., 2015;
Cooperstock et al., 2017; Frankovich et al., 2017; Pfeiffer et al., 2021b; Thienemann et al., 2017). The
treatment modalities recommended in these guidelines were assessed by CHBRP via rapid evidence
review for medical effectiveness in reducing or eliminating symptoms of PANDAS/PANS, and for possible
harms of these treatments. CHBRP also included information on known side effects of these treatment
modalities for other conditions in the pediatric population for additional context.
Outcomes Assessed
For studies of the impact of AB 907, CHBRP assessed effects on two outcomes: (1) reduction or
elimination of symptoms associated with PANDAS/PANS (e.g., OCD, tics, anxiety, irritability, or eating
disorders); and (2) harms associated with the treatments.
Study Findings
This following section summarizes CHBRP’s findings regarding the strength of evidence for the
effectiveness of antibiotics, psychotropic medications, behavioral therapy, plasma exchange, intravenous
immunoglobulin therapy (IVIG) and other immunomodulating medications addressed by AB 907,
specifically, for children affected by PANDAS/PANS. Each section is accompanied by a corresponding
figure. The title of the figure indicates the treatment for which evidence is summarized. The statement in
the box above the figure presents CHBRP’s conclusion regarding the strength of evidence about the

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effect of a particular treatment based on a specific relevant outcome and the number of studies on which
CHBRP’s conclusion is based. Definitions of CHBRP’s grading scale terms are included in the box below,
and more information is included in Appendix B.
The following terms are used to characterize the body of evidence regarding an outcome:
Clear and convincing evidence indicates that there are multiple studies of a treatment and that the large
majority of studies are of high quality and consistently find that the treatment is either effective or not
effective.
Preponderance of evidence indicates that the majority of the studies reviewed are consistent in their
findings that treatment is either effective or not effective.
Limited evidence indicates that the studies have limited generalizability to the population of interest and/or
the studies have a fatal flaw in research design or implementation.
Inconclusive evidence indicates that although some studies included in the medical effectiveness review
find that a treatment is effective, a similar number of studies of equal quality suggest the treatment is not
effective.
Insufficient evidence indicates that there is not enough evidence available to know whether or not a
treatment is effective, either because there are too few studies of the treatment or because the available
studies are not of high quality. It does not indicate that a treatment is not effective.
More information is available in Appendix B.
Findings on the Effectiveness and Harms of Antibiotics in Reducing or Eliminating
Symptoms for Children With PANDAS/PANS
Two systematic reviews (Johnson et al., 2021; Sigra et al., 2018) found three studies, all with moderate
risk of bias, (two randomized controlled trials [RCTs] and one cross-over RCT) assessing antibiotics as a
treatment option for children with PANDAS/PANS. The supplemental literature search did not identify any
additional studies.
Antibiotics for reducing or eliminating symptoms
One double-blind RCT (Murphy et al., 2017) assigned 31 children with PANS to receive azithromycin or
placebo (17 azithromycin, 14 placebo) for 4 weeks and a twice daily probiotic. Patients were recruited
online and from the University of South Florida Rothman Center Pediatric Neuropsychiatry, and were
included in the study if they met inclusion criteria (acute onset or relapse within 6 months of evaluation,
experienced OCD symptoms as measured on the Children’s Yale-Brown Obsessive Compulsive Scale,
scored moderate to high on the Clinical Global Impression Severity, had at least two co-occurring
neuropsychiatric symptoms [anxiety, emotional lability, tics, frequent urination, or food restrictive
symptoms], were aged 4 to 14 years, and were either on a stable dose of neuropsychiatric medication or
were not taking any). Participants were not tested for any active infections, but the authors assumed that
some participants in the group would have a Group A Strep or Mycoplasma infection. The small study’s
results found a significant treatment effect for the azithromycin group in one measure used to assess
OCD severity symptoms (OCD-Clinical Global Impressions Scale: seven participants [41.2%] vs. one
[7.2%] met treatment responder criteria at week 4; p = 0.045). In another measure for OCD severity
(Children’s Yale-Brown Obsessive Compulsive Scale) findings were not statistically significant; the
average reduction was 30.5% in the azithromycin group, and 17.2% in the placebo group (p = 0.258). Tic
severity also declined in both groups, showing no significant difference between groups on the Yale
Global Tic Severity Scale (p = 0.667), or the tic subscale of the Clinical Global Impression – Severity
Scale (p = 0.257).

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Prophylactic use of antibiotics
In a double-blind cross-over RCT, (Garvey et al., 1999) compared penicillin (250 mg, taken twice daily)
against a placebo with the intention of reducing neuropsychiatric exacerbations by preventing future
streptococcal infections. 37 children with PANDAS were randomized to receive either 4 months of
penicillin, followed by 4 months of placebo (n = 19), or 4 months of placebo, followed by 4 months of
penicillin (n = 18). Children were included in the study if they met DSM-III-R or DSM-IV criteria for a tic
and/or obsessive-compulsive disorder, had a history of sudden onset of symptoms that developed prior to
puberty, were aged 4 to 15 years, and had evidence of an association between streptococcal infections
and onset or exacerbations of symptoms. There was no limit on time since the onset of symptoms to be
eligible for participation. Children were excluded if tic or OCD severity required hospitalization, or if they
had a diagnosis of autism, pervasive developmental delay, mental retardation, other neurologic
diagnoses, or severe, comorbid psychiatric disorders. The authors found no significant differences in the
number of streptococcal infections between the two groups (14 in penicillin group, 21 in placebo), nor was
there a significant difference between groups in OCD severity (as measured by the (Children’s Yale-
Brown Obsessive Compulsive Scale), or tic severity (as measured by the Yale Global Tic Severity Scale).
Another double-blind RCT (Snider et al., 2005) of 23 children diagnosed with PANDAS examined the
prophylactic use of antibiotics on future streptococcal infections and neuropsychiatric exacerbations.
Children were included in the study if they met DSM-IV criteria for a tic and/or obsessive-compulsive
disorder, had a history of sudden onset of symptoms that developed prior to puberty, and had evidence of
an association between streptococcal infections and onset or exacerbations of symptoms. Participants
were tested via throat culture to ensure no active streptococcal infection was present and were
randomized to receive either penicillin (n = 11; 250 mg, taken twice daily), or azithromycin (n = 12; 250
mg, taken two times on 1 day of the week, with placebo 6 days a week) for 12 months. 23 out of 24
participants who started treatment completed the full length of the study. Streptococcal infections were
documented by review of medical records for the prior year to establish a baseline with a mean of 1.9
infection in the penicillin group and 2.4 infections in the azithromycin group. Participants in both groups
experienced fewer streptococcal infections during the study, compared to the streptococcal infections
documented in their medical records the year before (mean of 0.1, two total infections – one in each
group.) The study also reported significantly fewer neuropsychiatric exacerbations compared to the
baseline year, though these exacerbations were not well defined by the authors. Overall, the study found
no difference in the number of streptococcal infections or neuropsychiatric exacerbations between
patients receiving azithromycin and those receiving penicillin for 12 months.
Potential Harms from Antibiotic Use
Adverse effects reported in the Murphy study (2017) were higher for the azithromycin group and included
loose stools (52.94% in the treatment group, 7.14% in the placebo group). Four participants in the
azithromycin group had borderline prolonged QTc
43
intervals on ECG from 440 to 460 milliseconds (ms)
at the end of week 4 (414.56 ms, SD = ±19.39 ms), two of whom had a prolonged QTc at baseline.
Adverse effects were not reported in Garvey et al. (1999) or Snider et al. (2005). Studies of use of
antibiotics for other conditions in children have documented nausea, vomiting, abdominal pain,
Clostridium difficile (C. diff) infection, skin rash, hives, and anaphylaxis (Butler et al., 2022). Long-term
antibiotic use can contribute to antibiotic resistance.
43
A prolonged QTc or “long QT” indicates unusual electrical activity in the heart’s ventricles, as measured by an
electrocardiogram (EKG). Symptoms can include fainting during stress or exercise, gasping while sleeping, deafness,
muscle weakness, behavioral concerns, learning, memory, seizures, cardiac arrest, or sudden death (NIH, 2022).
Before puberty, a QTc <450 ms is considered normal, between 450 and 459 borderline, and ≥460 prolonged. After
puberty in males, a QTc between 460 and 469 is borderline and ≥470 is considered prolonged. In post-pubertal
females, 460 to 479 is borderline and ≥480 ms is considered prolonged (Berul, 2022).

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Summary of findings regarding antibiotic treatment or prophylaxis for patients with
PANDAS/PANS: There is inconclusive evidence based one systematic review including three small
clinical trials involving a total of 89 participants that antibiotics used for treatment or prophylaxis are
effective in reducing or eliminating symptoms with PANDAS/PANS.
Figure 2. Effectiveness of Antibiotics for Patients With PANDAS/PANS
Findings on the Effectiveness of Behavioral Therapies and Psychotropic Medications in
Reducing or Eliminating Symptoms for Children With PANDAS/PANS
One systematic review (Sigra et al., 2018) found two nonrandomized studies without concurrent
comparison groups that investigated the effect of cognitive behavioral therapy (CBT) on psychological
symptoms for patients with PANDAS/PANS. Both studies had a high risk of bias due to a lack of
randomization or blinding, and high attrition. The supplemental literature search did not identify any
additional studies. The waitlist-controlled trial (Storch et al., 2006) (seven participants) involved 14 CBT
sessions that occurred over the span of 3 weeks. Six of seven participants demonstrated significant
reductions in OCD symptoms (as measured by the Children’s Yale-Brown Obsessive Compulsive Scale)
but experienced no change in depression or anxiety symptoms.
In an uncontrolled trial, (Nadeau et al., 2015), eight participants with PANS completed 14 CBT sessions
on a twice-weekly schedule, and six were available for the final follow-up assessment. Participants who
completed the study experienced reductions in OCD symptoms (as measured by the Children’s Yale-
Brown Obsessive Compulsive Scale), but no changes in anxiety symptoms. The studies did not report
any harms or adverse events. The authors of the systematic review concluded that although CBT is an
evidence-based treatment for patients with OCD, it has not been sufficiently studied in patients with
PANDAS/PANS in a controlled setting. Thus, the evidence for CBT in reducing or eliminating OCD
symptoms for patients with PANDAS/PANS is insufficient.
CHBRP did not find any trials involving the use of psychotropic medications for use with pediatric patients
with PANDAS/PANS. A survey study found that SSRIs, antipsychotics, attention-deficit/hyperactivity
disorder (ADHD) medications, anxiolytics, and mood-stabilizing medications are widely prescribed for
children diagnosed with PANDAS/PANS (Calaprice et al., 2018).
Potential harms from CBT and psychotropic use
Harms of CBT for treatment of OCD or depression in children are considered minimal, though
comparative evidence on harms is limited (Uhre et al., 2020; Viswanathan et al., 2020). A systematic
review and meta-analysis of the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin and
norepinephrine reuptake inhibitors
44
(SNRIs) for all indications found a two-fold increase in rates of
suicidality and aggressive behavior in children and adolescents (Sharma et al., 2016). Another largescale
systematic review on adverse events reported in children using psychotropics found additional harms
(Solmi et al., 2020). Adverse events for antidepressants include nausea/vomiting, sedation, diarrhea,
headache, weight gain or loss, anorexia, and extrapyramidal symptoms.
45
For antipsychotics, adverse
44
SNRIs are medications that are FDA-approved to treat depression symptoms, as well as other conditions such as
fibromyalgia and generalized anxiety disorder.
45
Extrapyramidal symptoms include a broad range of drug-induced movement disorders and can include involuntary
muscle contractions, abnormal posturing, or repetitive movements. These movements can occur in many areas of the

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events varied by type and include weight gain, extrapyramidal symptoms, increased cholesterol, and
elevated glucose levels/diabetes. Medications for ADHD have some reported adverse events, including
abdominal pain, sedation, anorexia, insomnia, hypertension and prolonged QTc. Adverse events for
mood stabilizers also varied by type, and include sedation, nausea/vomiting, weight gain, weight loss, low
blood platelet count, and low white blood cell count.
Summary of findings regarding CBT and psychotropic medications for patients with
PANDAS/PANS: There is insufficient evidence that CBT is effective in reducing or eliminating OCD
symptoms for patients with PANDAS/PANS based on two very small studies identified in one systematic
review involving a total of 15 participants. There is insufficient evidence on the effectiveness of
psychotropic medications for reducing or eliminating behavioral symptoms for pediatric patients with
PANDAS/PANS as no published studies were identified.
Figure 3. Effectiveness of CBT for Patients With PANDAS/PANS
Figure 4. Effectiveness of Psychotropics for Patients With PANDAS/PANS
Findings on the Effectiveness of Immunomodulating Therapies in Reducing or Eliminating
Symptoms for Children with PANDAS/PANS
Nonsteroidal anti-inflammatory drugs (NSAIDs)
The two systematic reviews (Johnson et al., 2021; Sigra et al., 2018) did not identify any clinical trials
testing the use of NSAIDS in pediatric patients with PANDAS/PANS. The supplemental literature search
identified one retrospective observational study with no comparison group. The study (Brown et al.,
2017b) used electronic medical records from the Stanford PANS Clinic to describe the effects of NSAID
use on PANDAS/PANS flares (defined as an acute neuropsychiatric deterioration). Eligible patients
included those followed in the clinic who met PANS diagnostic criteria, as defined by Chang (Chang et al.,
2015), had at least one documented flare, and had adequate documentation to assess flare duration.
Patients who demonstrated no reduction in symptoms after their initial evaluation in the clinic, or who
required more aggressive treatment to achieve their baseline functioning were excluded from the study.
Patients who did not start NSAID treatment for a flare until more than 30 days after it started, or who had
received treatment with IVIG, high dose IV methylprednisolone, or plasma exchange within the past 50
days were also excluded. The final group included 95 patients and 390 flares and included patients on
prophylactic NSAIDs (used before onset of a flare) and NSAID treatment started within 30 days after the
flare. NSAIDs included ibuprofen, naproxen, sulindac, and celecoxib. Although most flares were not
treated with NSAIDs, the study found that treatment after the flare symptoms began or prophylactic use of
NSAIDs were associated with a shorter flare duration than flares not treated with NSAIDs (prophylactic
NSAID difference 4 weeks, (95% CI [1.85-6.24]; p < 0.01; early NSAID use difference 2.5 weeks (95% CI
body, including the back, neck, jaw, eyes, abdominal wall and pelvic muscle, facial and tongue muscles, and
extremities (D'Souza and Hooten, 2023).

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[0.43-4.68]; p < 0.02). It also found that flare duration did not differ significantly between NSAIDs used
prophylactically or prescribed within 30 days of flare onset (p = 0.26).
Potential Harms of NSAIDs
Participants in the Brown study experienced side effects including abdominal pain (5), skin rash (1),
bruising (1), high levels of protein in urine (3), and clinically insignificant elevated liver enzymes (1). Long
term or chronic use of NSAIDs can adversely affect the digestive, renal, cardiovascular, hepatic, and/or
hematologic systems (Ghlichloo and Gerriets, 2022).
Summary of findings regarding NSAIDS for patients with PANDAS/PANS: There is insufficient
evidence that NSAIDs are effective in reducing or eliminating symptoms for patients with PANDAS/PANS
based on a lack of evidence (no controlled clinical trials and 1 retrospective observational study without a
comparison group).
Figure 5. Effectiveness of NSAIDS for Patients With PANDAS/PANS
Corticosteroids
The two systematic reviews (Johnson et al., 2021; Sigra et al., 2018) did not identify any clinical trials
evaluating the use of oral corticosteroids in pediatric patients with PANDAS/PANS. The supplemental
literature search identified 1 retrospective observational study with no comparison group on the use of
oral corticosteroids on children having PANDAS/PANS flares (Brown et al., 2017a). The investigators
reviewed electronic medical records from the Stanford PANS Clinic to identify eligible patients who met
PANS or PANDAS research diagnostic criteria (Chang et al., 2015; Swedo et al., 1998, 2012) and who
had been treated with steroids during an initial episode or a subsequent flare of symptoms. Patients who
required more aggressive treatment to alleviate symptoms were excluded from the study, including
aggressive disease-modifying treatments such as chronic use of IVIG or high dose IV
methylprednisolone, as were patients whose records did not document the duration of the flare. The final
group included 98 patients (403 flares), 54 of whom (85 flares) had received treatment with
corticosteroids. The study found that children treated with corticosteroids experienced a shorter flare
duration (6.4 ± 1.5 weeks) than those not treated with corticosteroids (mean duration of 11.4 ± 8.6 weeks
(p < 0.001)). In a multilevel model adjusted for demographics, disease and treatment variables, use of
oral corticosteroids was associated with flares that were 3.5 weeks shorter (95% CI [1.10-5.95]).
Potential Harms From Corticosteroid Use
Temporary side effects were reported for 44% of 102 corticosteroid courses, including escalation of
symptoms: OCD symptoms (10), anxiety (16), emotional lability/moodiness (12), irritability/agitation (15),
sleep disturbance (10), tics (7), aggression/anger/rage (4), urinary symptoms (5), mania (3), sensory
amplification (3), hyperactivity (2), hallucinations (2), vision abnormalities (2), behavior regression (2), and
flat affect (1). In 3 patients, steroids were stopped due to worsened neuropsychiatric symptoms. Of the 15
patients who received a corticosteroid course for >5 days, or more than 3 courses within 1 month, 2
experienced weight gain, 4 experienced weight gain and Cushingoid features,
46
and 2 experienced only
Cushingoid features. Adverse effects noted from treatment of other conditions are seen in up to 90% of
46
Cushingoid features can include increased fat deposits around the face and torso, thin arms and legs, acne,
increased facial hair, muscle weakness in the shoulder and hips, thin skin, and purple abdominal striae (Chaudhry
and Singh, 2023).

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patients who take corticosteroids for more than 60 days and include suppression of the hypothalamic-
pituitary-adrenal (HPA) axis, Cushingoid features, diabetes and hyperglycemia, myopathy, psychiatric
disturbances, immunosuppression, cardiovascular disease, and effects on gastrointestinal and skin and
bones (Hodgens and Sharman, 2022).
Summary of findings regarding corticosteroids for patients with PANDAS/PANS: There is
insufficient evidence that oral corticosteroids are effective on reducing symptoms for patients with
PANDAS/PANS based on a lack of controlled clinical trials and a single retrospective observation study
with no comparison group. CHBRP did not find any studies on the use of intravenous corticosteroids for
patients with PANDAS/PANS.
Figure 6. Effectiveness of Corticosteroids for Patients With PANDAS/PANS
Intravenous immunoglobulin (IVIG)
Both systematic reviews (Johnson et al., 2021; Sigra et al., 2018) identified two small clinical trials
(Perlmutter et al., 1999; Williams et al., 2016) testing the use of IVIG for treating OCD and tic symptoms
in patients with PANDAS/PANS among a total of 63 patients. The supplemental search identified two
additional small uncontrolled studies (Hajjari et al., 2022; Melamed et al., 2021) describing a total of 31
patients.
In the Perlmutter trial, 29 patients were randomized to receive IVIG, placebo, or plasma exchange. To
meet eligibility criteria, patients had to meet DSM-III criteria for a tic and/or OCD disorder, experienced a
sudden onset (or episodic course) of neuropsychiatric symptoms before puberty, evidence of an
association between streptococcal infection and onset or exacerbation of signs and symptoms, and
current exacerbation severe enough to cause significant distress and interfere with child’s home, school,
and/or social relations. Patients were excluded if they had a history of Sydenham’s chorea, rheumatic
fever, autism, schizophrenia or other psychotic or neurological disorder, an autoimmune disorder, or other
medical illness. Nine patients were randomized into the IVIG group, five of whom were taking some type
of psychotropic at the time of treatment (three SSRIs, one SSRI + another antidepressant, and one
neuroleptic + SSRI). 10 patients were randomized into the placebo group, for which 5 were also taking
some type of psychotropic at the time of treatment (two SSRIs, three SSRI + another antidepressant, and
one neuroleptic). Participants who were randomized into the IVIG or placebo (saline solution given in the
same manner as IVIG) groups were blind to their treatment, however, those receiving plasma exchange
were not blinded. The IVIG and placebo groups received 2 consecutive days of treatment (IVIG at 1g/kg
dose). At 1 month follow-up, OCD symptoms (as measured by the Children’s Yale-Brown Obsessive
Compulsive Scale) in the IVIG group showed greater reductions compared to the placebo group (45%
reduction for IVIG group, 3% reduction for placebo group). Both the IVIG and placebo groups
demonstrated a similar reduction in tic symptoms (as measured by the Tourette Syndrome Unified Rating
Scale) (19% reduction for IVIG group, 12% reduction for placebo group). The Williams trial (35 patients)
used a similar study design to Perlmutter but found no significant difference in reduction of OCD
symptoms (as measured by the same Obsessive-Compulsive Scale) between the IVIG group and the
placebo at 6-week follow-up (22% reduction for IVIG group, 11% reduction for placebo group).
An uncontrolled study (Melamed et al., 2021) provided all 21 participants with IVIG treatment at 1g/kg
every 21 days, over a period of 18 weeks (six infusions). Eligibility criteria included age 4 to 16 years,
diagnosed with moderate to severe PANS that was confirmed via parent questionnaire (PANS Scale –

Analysis of California Assembly Bill 907
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Parent Version), with symptoms that were unresponsive to prior treatments. Participants were excluded if
they had a history of rheumatic fever or Sydenham’s chorea, previous IVIG therapy within 6 months of
screening, or use of corticosteroids within 6 weeks of screening. At 26-week follow-up, OCD symptoms
(as measured by the Children’s Yale-Brown Obsessive Compulsive Scale) reduced from a baseline mean
of 22.10, to 8.52. At the same timepoint, tic symptoms (as measured by the Yale Global Tic Severity
Scale) had reduced from a baseline mean of 36.81, to 12.29.
A second uncontrolled study (Hajjari et al., 2022) provided 10 children with a pre-existing diagnosis of
post-infectious PANDAS/PANS, with 2g/kg IVIG treatment once/month for 3 months. Eligibility criteria
included aged 4 to 17 years, diagnosed with post-infectious PANDAS/PANS (using criteria from Swedo et
al., 2012), and no use of IVIG within the past 6 months. Exclusion criteria included having an acute or
chronic disease that would put the patient at risk, history of serious reactions to blood-derived products,
pregnancy, kidney disease, taking medications with immunosuppressants, immunomodulators, or long-
term corticosteroid use, history of drug abuse, subjects/families who could not provide independent
informed consent, or participation in another clinical trial within past 30 days. Six of the 10 participants
had pre-existing diagnosed or suspected neurodevelopmental disorders including autism, ADHD, and
epilepsy. The study reported on OCD symptoms (using the Children’s Yale-Brown Obsessive Compulsive
Scale) and found a nonsignificant reduction in mean scores from baseline to 4 months later (M = 24, SD,
7.80. M = 17.8, SD, 7.67; p = 0.005). The PANS Scale, a scale that rates severity of 12 possible
symptoms from “Absent” to “Extreme” and is calculated to form a composite score, was completed via
interview with the patient and parent. Mean scores for the scale declined by 33% after 1 month (81.2% to
54.0%), however the effect was global, with no specific symptom improvement.
Potential Harms From IVIG Use
Adverse events were common with IVIG but generally transient. In the Perlmutter trial, 6 of the 9 children
who received IVIG experienced adverse effects including nausea/vomiting (5), headache (3), and fever
(4). Two of the 10 children in the placebo group experienced nausea/vomiting, and 1 experienced a
headache. In the Williams trial, adverse effects included headache, sore throat, nausea/vomiting,
muscle/bone/joint pain, fatigue, and anxiety. Adverse effects in the Melamed study (2021) included
headache, nausea/vomiting, and rash. In the Hajjari study, adverse effects included headache, neck
and/or pain, nausea, vomiting, irritability, and fatigue. One child developed temporary anemia, and
another experienced a brief allergic reaction. Aseptic meningitis has also been identified as another
common side effect of IVIG infusion (Cooperstock et al. 2017).
Summary of findings regarding IVIG for patients with PANDAS/PANS: There is inconclusive
evidence from 2 small, controlled studies with conflicting evidence, and 2 small, uncontrolled studies
involving 95 participants in total, that IVIG is effective in reducing tic and/or OCD symptoms for patients
with PANDAS/PANS.
Figure 7. Effectiveness of IVIG for Patients With PANDAS/PANS

Analysis of California Assembly Bill 907
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Therapeutic plasma exchange
Both systematic reviews (Johnson et al., 2021; Sigra et al., 2018) identified 1 small trial (Perlmutter et al.,
1999) testing the use of plasma exchange on alternate days for five to six treatments over 10 to 12 days
in pediatric patients with PANDAS/PANS. The supplemental literature search did not identify any
additional studies. In the Perlmutter trial, 29 patients were randomized to receive IVIG, placebo
(simulating the IVIG infusion process), or plasma exchange. Ten participants were randomized into the
plasma exchange group; of these, 7 patients were taking some type of psychotropic at the time of
treatment (two were taking SSRIs, two neuroleptics, and three were taking a neuroleptic and SSRI). Due
to the design of the study and the nature of the treatment (patients must be connected by IV to a plasma
pheresis machine for 1 to 2 hours), patients who received the plasma exchange treatment were aware
that they were receiving that intervention. At 1-month follow-up, OCD symptoms (as measured by the
Children’s Yale-Brown Obsessive Compulsive Scale) for the plasma exchange group decreased from an
average 22.5 at baseline to an average of 9.5 (p < 0.05), a statistically significant difference. For tic
symptoms (as measured by the Tourette Syndrome Unified Rating Scale), the plasma exchange group
experienced a statistically significant decrease from an average of 21.7 to 11.0 (p < 0.05). Additional
results on global impairment and severity were provided, however, these scales were not adequately
described.
Potential Harms From Plasma Exchange Use
Adverse effects for the plasma exchange group in the Perlmutter trial (1999) included pallor, dizziness,
nausea, vomiting, and anxiety. Additional possible complications of plasma exchange include reduction in
serum calcium or potassium with related symptoms including paresthesia, tetany, and arrhythmias.
Anaphylaxis may also occur (Kaplan and Fridey, 2022).
Summary of findings regarding plasma exchange for patients with PANDAS/PANS: There is
insufficient evidence from 1 trial of 10 patients that plasma exchange is effective on reducing symptoms
for patients with PANDAS/PANS based on a lack of controlled clinical trials.
Figure 8. Effectiveness of Plasma exchange for Patients With PANDAS/PANS
Rituximab
CHBRP did not find any studies involving the use of rituximab for pediatric patients with PANDAS/PANS.
Potential Harms From Rituximab Use
Possible side effects for rituximab can include fever, headache, rash, fatigue, infection, hemolysis or other
hemolytic reactions, anaphylaxis, renal failure, thrombosis, dermatological reactions, neutropenia, lung
injury, seizures, and death (Frankovich et al., 2017; Lexicomp, 2023).
Summary of findings regarding rituximab for patients with PANDAS/PANS: There is insufficient
evidence that rituximab is effective on reducing symptoms for patients with PANDAS/PANS based on a
lack of controlled clinical trials or other studies.

Analysis of California Assembly Bill 907
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Figure 9. Effectiveness of Rituximab for Patients With PANDAS/PANS
Mycophenolate mofetil
CHBRP did not find any studies involving the use of mycophenolate mofetil for pediatric patients with
PANDAS/PANS.
Possible Harms From Mycophenolate Mofetil Use
Possible side effects of mycophenolate mofetil can include sensory disturbances, cytopenia, dizziness,
nausea, diarrhea, abdominal pain, dermatologic reactions, hemolytic reactions, abnormal renal or hepatic
function, malignant neoplasms, increased risk of sepsis or other infections, including CMV
(cytomegalovirus), herpes zoster, BK virus, hepatitis B, and hepatitis C (Frankovich et al., 2017).
Summary of findings regarding mycophenolate mofetil for patients with PANDAS/PANS: There is
insufficient evidence that mycophenolate mofetil is effective on reducing symptoms for patients with
PANDAS/PANS based on a lack of controlled clinical trials.
Figure 10. Effectiveness of Mycophenolate Mofetil for Patients With PANDAS/PANS
Vitamin D
CHBRP did not find any studies involving the use of vitamin D for pediatric patients with PANDAS/PANS.
Summary of findings regarding vitamin D for patients with PANDAS/PANS: There is insufficient
evidence that vitamin D is effective on reducing symptoms for patients with PANDAS/PANS based on a
lack of controlled clinical trials.
Figure 11. Effectiveness of Vitamin D for Patients With PANDAS/PANS
Summary of Findings
Table 3 summarizes evidence of the effectiveness of antibiotics, behavioral therapies, psychotropics,
NSAIDs, corticosteroids, IVIG, plasma exchange, rituximab, mycophenolate mofetil, and vitamin D on
reducing or eliminating symptoms for pediatric patients with PANDAS/PANS. Evidence is reported
separately for: (1) the treatment’s effectiveness at reducing or eliminating symptoms of PANDAS/PANS;
and (2) reported harms associated with the treatment. Overall, the evidence is insufficient or inconclusive

Analysis of California Assembly Bill 907
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that any of these treatments are effective at reducing prominent symptoms, such as OCD symptoms, tics,
or eating restrictions, for pediatric patients with PANDAS/PANS. As stated in the introduction, research
available for PANDAS/PANS is very limited; studies are few, small, and demonstrate moderate to high
levels of bias. This analysis included a total of approximately 394 individual participants though this
number is likely an overestimate due to probable overlap of the patient populations described in the
Brown et al., 2017 (95 patients) and Brown et al., 2017a (98 patients) studies. Additional studies involving
controlled clinical trials, larger sample sizes, and clear eligibility criteria are necessary to determine which
treatments are effective for children with PANDAS/PANS.
Table 3. Summary of Evidence of Medical Effectiveness of Test/Treatment/Service
Type of
Treatment
Evidence Level for
Reducing or
Eliminating
Symptoms of
PANDAS/PANS
Evidence of Possible Harms
Antibiotics
Inconclusive evidence
Side effects can include loose stools, and prolonged QTc. Studies of use
of antibiotics for other conditions in children have documented nausea,
vomiting, abdominal pain, C. diff infection, skin rash, hives, and
anaphylaxis. Long term antibiotic use can contribute to antibiotic
resistance.
Behavioral
therapy (CBT)
Insufficient evidence
Insufficient evidence.
Psychotropics
Insufficient evidence
Antidepressants: nausea/vomiting, headache, diarrhea, sedation, weight
gain or loss, extrapyramidal symptoms47, anorexia, aggression, and
suicidality.
Antipsychotics: weight gain, extrapyramidal symptoms, increased
cholesterol, and elevated glucose levels/diabetes.
ADHD medications: abdominal pain, sedation, anorexia, insomnia,
hypertension, and prolonged QTc48.
Mood stabilizers: nausea/vomiting, sedation, weight gain, weight loss,
low blood platelet count, and low white blood cell count.
NSAIDs
Insufficient evidence
Abdominal pain, skin rash, bruising, proteinuria, and clinically
insignificant transaminitis. Long term use can affect the digestive, renal,
cardiovascular, hepatic, and/or hematologic systems.
Corticosteroids
Insufficient evidence
Psychiatric adverse effects can include escalation of symptoms including
OCD symptoms, anxiety, emotional lability/moodiness,
irritability/agitation, sleep disturbance, tics, aggression/anger/rage,
urinary symptoms, mania, sensory amplification, hyperactivity,
hallucinations, vision abnormalities, behavior regression, and flat affect.
Other adverse effects can include weight gain, Cushingoid features,
hyperglycemia, diabetes, myopathy, psychiatric disturbances,
immunosuppression, cardiovascular disease, and effects on
gastrointestinal tract, skin, and bone.
47
Extrapyramidal symptoms include a broad range of drug-induced movement disorders and can include involuntary
muscle contractions, abnormal posturing, or repetitive movements. These movements can occur in many areas of the
body, including the back, neck, jaw, eyes, abdominal wall and pelvic muscle, facial and tongue muscles, and
extremities (D'Souza and Hooten, 2023).
48
A prolonged QTc or “long QT” indicates unusual electrical activity in the heart’s ventricles, as measured by an
electrocardiogram (ECG). Symptoms can include fainting during stress or exercise, gasping while sleeping, deafness,
muscle weakness, behavioral concerns, learning, memory, seizures, cardiac arrest, or sudden death (NIH, 2022).

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IVIG
Inconclusive evidence
Fever, headache, sore throat, nausea/vomiting, muscle/bone/joint pain,
fatigue, irritability, anxiety, and aseptic meningitis.
Plasma
exchange
Insufficient evidence
Pallor, dizziness, nausea/vomiting, anxiety, reduction in serum calcium
or potassium, paresthesias muscle spasms, arrhythmias, and
anaphylaxis.
Rituximab
Insufficient evidence
Fever, headache, rash, fatigue, infection, hemolysis or other hemolytic
reactions, anaphylaxis, renal failure, thrombosis, dermatological
reactions, neutropenia, lung injury, seizures, and death.
Mycophenolate
mofetil
Insufficient evidence
Sensory disturbances, cytopenia, dizziness, nausea, diarrhea,
abdominal pain, dermatologic reactions, hemolytic reactions, abnormal
renal or hepatic function, malignant neoplasms, increased risk of sepsis
or other infections, including cytomegalovirus, herpes zoster, BK virus,
hepatitis B, and hepatitis C.
Vitamin D
Insufficient evidence
Insufficient evidence.
Source: California Health Benefits Review Program, 2023.
Key: CBT = cognitive behavioral therapy; C. diff = Clostridium difficile; IVIG = intravenous immunoglobulin; NSAIDs = nonsteroidal
anti-inflammatory drugs.

Analysis of California Assembly Bill 907
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BENEFIT COVERAGE, UTILIZATION, AND COST IMPACTS
As discussed in the Policy Context section, AB 907, as amended on March 16, 2023, would require
health plans regulated by the Department of Managed Health Care (DMHC) and health policies regulated
by the California Department of Insurance (CDI) to provide coverage for the prophylaxis, diagnosis, and
treatment of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections
(PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). Covered treatments must
include antibiotics, medications and behavioral therapies to manage neuropsychiatric symptoms,
immunomodulating medicines, plasma exchange, and intravenous immunoglobulin (IVIG) therapy.
AB 907 applies to enrollees in health plans and health policies regulated by the Department of Managed
Health Care (DMHC)
49
or the California Department of insurance (CDI) as well as to beneficiaries in Medi-
Cal. This section reports the potential incremental impacts of AB 907 on estimated baseline benefit
coverage, utilization, and overall cost.
Analytic Approach and Key Assumptions
Assumptions regarding utilization
• To estimate utilization of diagnostic tests for PANDAS/PANS, CHBRP relied on published clinical
guidelines to identify relevant diagnostic tests and estimate their frequency of use in diagnosis
(Chang et al., 2015; Cooperstock et al., 2017; Frankovich et al., 2017; Pfeiffer et al., 2021;
Thienemann et al., 2017). For more details on estimated utilization of diagnostic tests, see
Appendix C, Tables 8 and 9.
• To estimate utilization of treatments for PANDAS/PANS, CHBRP used estimates from the
literature (Frankovich et al., 2017; Thienemann et al., 2017), treatment guidelines from the
PANDAS Physicians Treatment Network (Chang et al., 2015; Cooperstock et al., 2017;
Frankovich et al., 2017; Pfeiffer et al., 2021; Thienemann et al., 2017), and consultations with a
clinical expert. CHBRP assumed different treatment trajectories based on the severity of
symptoms. For more details on estimated utilization of treatments for PANDAS/PANS, see
Appendix C, Tables 8 and 9.
• At baseline and postmandate, a variety of access and supply barriers limit treatment utilization for
PANDAS/PANS at baseline. These include:
o There are few clinicians with knowledge of how to diagnose or treat PANDAS/PANS, and
the few clinics currently accepting PANDAS/PANS patients accept only a small (<10%) of
patients (Tang et al., 2021). Moreover, PANDAS/PANS treatment often requires
multidisciplinary teams and coordination of care given the complexity of the syndromes
and the myriad symptoms. Such multidisciplinary teams may be challenging to access for
many families, and there are few clinics offering this type of multidisciplinary, specialized
care (~10 in the United States). In California, there are only two clinics specializing in
PANDAS/PANS care, one each at UCLA and Stanford, which may result in limited
access. The lack of availability of clinics and physicians with knowledge and willingness
to treat PANDAS/PANS often requires families to travel long distances to find care. A
survey by O’Dor et al. (2022) of 441 primary caregivers of patients with PANDAS/PANS
found that 16% of families reported traveling more than 500 miles for treatment and that
62% reported traveling more than 50 miles (O'Dor et al., 2022).
49
This includes approximately 73% of enrollees associated with the California Public Enrollees’ Retirement System
(CalPERS).

Analysis of California Assembly Bill 907
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o Delayed diagnosis, misdiagnosis, and children’s suppression of behaviors during
assessments are also treatment barriers in PANDAS/PANS identified in the literature
(O'Dor et al., 2022; Tang et al., 2021).
o As noted in the Background on PANDAS and PANS section, IVIG has been subject to
intermittent national shortages due to growing demand as a treatment for various
conditions and its manufacturing process (FDA, 2022; Rhodes, 2021).
o As detailed in the Background on PANDAS and PANS and Medical Effectiveness
sections, there is a lack of literature on effective treatments for PANDAS/PANS, which
limits clinicians’ willingness to use various therapies such as plasma exchange and IVIG.
o CHBRP assumed that the aforementioned diagnostic, access, and supply barriers would
continue postmandate, resulting in low utilization of IVIG and plasma exchange.
• Access barriers are likely particularly acute among Medi-Cal enrollees, given low reimbursement
rates and limited participation of providers and specialists. Moreover, other access barriers, such
as transportation barriers and lower levels of health literacy with which to navigate a complex
system may also limit Medi-Cal enrollees’ access to PANDAS/PANS care.
Assumptions regarding factors that would not change postmandate
• CHBRP assumed that carriers would still impose some utilization management strategies which
would result in low rates of some PANDAS/PANS treatments utilization postmandate, specifically
IVIG, plasma exchange, and rituximab.
• As detailed in the Policy Context section, CHBRP assumed that cost sharing for treatments
outlined in the bill would not change.
• For some enrollees, medications are covered by and/or regulated by separate entities. Because
AB 907 does not require creation of a pharmacy benefit – only compliant benefit coverage when a
pharmacy benefit is present – baseline benefit coverage for enrollees without a pharmacy benefit
or whose pharmacy benefit is not regulated by DMHC or CDI is compliant. See Table 2 in the
Policy Context sections for assumptions about the coverage of pharmacy/medical benefits.
Additional assumptions
• CHBRP did not model the use of prophylactic antibiotic therapy or mycophenolate mofetil for
PANDAS/PANS at baseline or postmandate given the lack of conclusive evidence on this practice
and based on informal consultations with clinical experts in the field (Cooperstock et al., 2017;
Pfeiffer et al., 2021).
For further details on the underlying data sources and methods used in this analysis, please see
Appendix C.
Baseline and Postmandate Benefit Coverage
CHBRP queried health plans and policies in California to determine baseline benefit coverage and the
impacts of AB 907.

Analysis of California Assembly Bill 907
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Diagnostics for PANDAS/PANS
At baseline, 100% of enrollees with health insurance that would be subject to AB 907 have coverage that
includes diagnostic tests associated with PANDAS/PANS recommended by various guidelines for
diagnosing PANDAS/PANS. These include blood tests, throat cultures, and nose swabs. See Table 8 in
Appendix C for a list of relevant diagnostic tests.
Treatment for PANDAS/PANS
At baseline, 100% of enrollees with health insurance that would be subject to AB 907 have coverage that
includes some, but not all, treatments for PANDAS/PANS. Coverage by type of treatment varies
substantially. CHBRP found that 100% of enrollees have health insurance that includes antibiotics
commonly used for PANDAS/PANS and some oral prescription immunomodulatory medications including
steroids and nonsteroidal anti-inflammatory medications (NSAIDs). Similarly, 100% of enrollees have
health insurance that includes coverage for psychotropics used for treatment of neuropsychiatric
symptoms of PANDAS/PANS, including selective serotonin receptor inhibitors (SSRIs), benzodiazepines,
and antipsychotics. One hundred percent of enrollees also have health insurance that includes coverage
of behavioral health therapies used for treatment of neuropsychiatric symptoms of PANDAS/PANS,
including cognitive behavioral therapy (CBT).
Health plans and insurers generally use clinical guidelines to make medical necessity determinations
about treatments such as IVIG, rituximab, and plasma exchange services, with some health plan/insurer
policies for PANDAS/PANS noting that IVIG is not deemed medically necessary. Based on these policies,
CHBRP estimates that 0% of enrollees have health insurance that includes coverage of IVIG, rituximab,
and plasma exchange services for the treatment of PANDAS/PANS. Benefit coverage for relevant
PANDAS/PANS services, including IVIG, rituximab, and plasma exchange services, among enrollees in
commercial and CalPERS DMHC-regulated plans or CDI-regulated policies would increase to 100%
based on the CHBRP assumption that all noncompliant plans and policies at baseline would become
compliant postmandate.
Baseline and Postmandate Utilization
Diagnostics for PANDAS/PANS
CHBRP estimates that at baseline, 15,410 enrollees use diagnostic tests for PANDAS/PANS.
50
These
include various blood tests, throat cultures, and nose swabs. CHBRP estimates that for every 23 children
tested for PANDAS/PANS using these diagnostic tests, 1 child is diagnosed with PANDAS/PANS and 22
children are not given this diagnosis. Given that 100% of enrollees already have baseline coverage,
CHBRP estimates no changes in utilization for these diagnostic tests.
Treatment for PANDAS/PANS
At baseline, CHBRP estimates that 670 enrollees have a PANDAS/PANS diagnosis (Table 1).
51
Among
these enrollees, average annual utilization of oral prescription medications used for the treatment and
management of neuropsychiatric symptoms (including medications such as antibiotics, steroids, NSAIDs,
and psychotropics) is 17.8 prescriptions, each with a 30-day supply. At baseline, annual utilization of CBT
is 20 visits per year.
52
Given that 100% of enrollees already have baseline coverage for these
50
CHBRP estimated the number of enrollees who would use diagnostic tests for PANDAS/PANS by estimating the
number of enrollees diagnosed annually with severe OCD. See Appendix C, Detailed Cost Notes Regarding
Analysis-Specific Caveats and Assumptions for more detail about this assumption.
51
Refer to Appendix C for an explanation of how the prevalence of PANDAS/PANS was estimated.
52
See Appendix C Tables 8 and 9 for further explanation of how this baseline utilization was calculated.

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medications and behavioral health therapies such as CBT, CHBRP estimated no changes in utilization of
these specific medications and CBT services postmandate. See estimates in Table 1.
CHBRP estimates that IVIG, rituximab, and plasma exchange have extremely limited use at baseline.
Although coverage of these therapies would increase to 100% postmandate, it is important to note that
benefit coverage does not equate to utilization. As noted in the Analytic Approach and Key Assumptions
section above, a variety of barriers limit access to such treatments at baseline and postmandate. These
include a very limited number of providers with knowledge of how to treat PANDAS/PANS, a limited
availability of clinics that offer such treatments, and supply shortages of these treatments. Moreover,
continued use of utilization management approaches such as prior authorization may continue to limit
access to IVIG, rituximab, and plasma exchange. CHBRP assumed that only enrollees with moderate or
severe PANDAS/PANS would thus be prescribed and administered IVIG and rituximab. CHBRP assumed
that within this group, only a small proportion (20%) of enrollees would be able to access these
treatments postmandate due to the aforementioned supply and access barriers. Thus, CHBRP estimates
that average annual utilization of IVIG among all enrollees with PANDAS/PANS would increase to 0.7
infusion therapy sessions per year. This results in an estimated 90 enrollees with moderate or severe
PANDAS/PANS utilizing IVIG at least once per year, with greater expected utilization among those with
severe PANDAS/PANS. CHBRP estimates that average annual utilization of rituximab would increase to
0.1 infusion therapy sessions. This results in an estimated 22 enrollees with severe PANDAS/PANS
utilizing an average of 3 rituximab infusions per year. CHBRP estimated no change in the use
53
of plasma
exchange services given their low availability and the lack of evidence of their effectiveness in
PANDAS/PANS.
Baseline and Postmandate Per-Unit Cost
Diagnostics for PANDAS/PANS
At baseline, CHBRP estimates that average per-unit costs of diagnostic tests are $30. The estimated
average cost per enrollee is $270. CHBRP estimates no impact on unit cost would be expected
postmandate.
Treatment for PANDAS/PANS
At baseline, CHBRP estimates that average per-prescription costs of oral prescription medications,
including antibiotics, corticosteroids, nonsteroidal anti-inflammatory drugs, selective serotonin uptake
inhibitors, benzodiazepines, and antipsychotics, is $7 for a 30-day supply, the per-visit cost of CBT is
$142, the per-unit cost of a rituximab infusion session is $9,566, the per-unit cost of IVIG is $4,312, and
the per-unit cost of a plasma exchange therapy session is $2,136.
54
CHBRP estimates no impact on unit
cost postmandate for any of these therapies.
Baseline and Postmandate Expenditures
Table 4 and Table 5 present baseline and postmandate expenditures by market segment for DMHC-
regulated plans and CDI-regulated policies. The tables present per member per month (PMPM)
premiums, enrollee expenses for both covered and noncovered benefits, and total expenditures
(premiums as well as enrollee expenses).
AB 907 would increase total net annual expenditures by total net annual $2,990,000, or total net annual
0.0020%, for enrollees with DMHC-regulated plans (including DMHC-regulated Medi-Cal Managed Care
53
This estimate is based on informal consultations with clinical experts in PANDAS/PANS.
54
Cost estimates are estimated using both commercial and Medi-Cal claims data. See Appendix C for more details.

Analysis of California Assembly Bill 907
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Plans) and CDI-regulated policies. This is due to a $2,838,000 increase in total health insurance
premiums, plus $153,000 paid by enrollees for covered and/or noncovered benefits.
Premiums
Overall, CHBRP estimates premiums would increase by $2,837,000 postmandate as a result of AB 907.
Changes in premiums as a result of AB 907 would vary by market segment. Note that such changes are
related to the number of enrollees (see Table 1, Table 4, and Table 5), with health insurance that would
be subject to AB 907. The largest increases are among large group plans in DMHC-regulated plans
($0.0098 PMPM, a 0.0016% increase). The smallest increases are among DMHC-regulated individual
plans ($0.0034 PMPM, a 0.0005% increase), DMHC-regulated Medi-Cal 65+ plans (no change), and CDI-
regulated individual plans ($0.0044 PMPM, a 0.0007% increase).
For Medi-Cal beneficiaries enrolled in DMHC-regulated plans, among those under 65, premiums would
increase by $0.0152 (a 0.0060% increase), and among those 65 and over, there would be no impact. In
addition to the estimated $1,471,000 increase in premiums for the 8.8 million Medi-Cal beneficiaries
enrolled in DMHC-regulated plans, a proportional increase of $370,000 is estimated to occur for the 2.0
million beneficiaries enrolled in county organized health system (COHS) managed care. CHBRP assumes
the two populations to be relatively similar and to have relatively similar benefit coverage.
Enrollee Expenses
AB 907-related changes in cost sharing for covered benefits (deductibles, copays, etc.) and out-of-pocket
expenses for noncovered benefits would vary by market segment. Note that such changes are related to
the number of enrollees (see Table 1, Table 4, and Table 5) with health insurance that would be subject
to AB 907 expected to use the relevant treatments during the year after enactment.
CHBRP projects no change to copayments or coinsurance rates but does project an increase in utilization
of two treatments for PANDAS/PANS – IVIG and rituximab – and therefore an increase in enrollee cost
sharing. It is possible that some enrollees incurred expenses related to IVIG, rituximab infusions, or
plasma exchange therapy at baseline for which coverage was denied, but CHBRP cannot estimate the
frequency with which such situations occur and so cannot offer a calculation of impact.
CHBRP finds the largest increases in enrollee cost sharing for covered benefits are for enrollees in
individual plans and small group plans (see Table 5). Increases in enrollee cost sharing in individual plans
range from $0.0009 PMPM in DMHC-regulated plans to $0.0014 PMPM in CDI-regulated plans.
Increases in enrollee cost sharing in small group plans range from $0.0016 PMPM in DMHC-regulated
plans to $0.0020 PMPM in CDI-regulated plans.
Potential Cost Offsets of Savings in the First 12 Months After Enactment
CHBRP does not project any cost offsets or savings in health care that would result because of the
enactment of provisions in AB 907. While it is possible that use of treatments and services for
PANDAS/PANS such as early use of IVIG or rituximab could reduce psychiatric-related hospitalizations,
CHBRP is unable to quantify the fiscal impacts of these changes due to lack of conclusive evidence about
the effectiveness of these treatments.
Postmandate Administrative Expenses and Other Expenses
CHBRP estimates that the increase in administrative costs of DMHC-regulated plans and/or CDI-
regulated policies will remain proportional to the increase in premiums. CHBRP assumes that if health
care costs increase as a result of increased utilization or changes in unit costs, there is a corresponding
proportional increase in administrative costs. CHBRP assumes that the administrative cost portion of
premiums is unchanged. All health plans and insurers include a component for administration and profit in
their premiums.

Analysis of California Assembly Bill 907
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Other Considerations for Policymakers
In addition to the impacts a bill may have on benefit coverage, utilization, and cost, related considerations
for policymakers are discussed below.
Postmandate Changes in the Number of Uninsured Persons
Because the change in average premiums does not exceed 1% for any market segment (see Table 1,
Table 4, and Table 5), CHBRP would expect no measurable change in the number of uninsured persons
due to the enactment of AB 907.
Changes in Public Program Enrollment
CHBRP estimates that the mandate would produce no measurable impact on enrollment in publicly
funded insurance programs due to the enactment of AB 907.
How Lack of Benefit Coverage Results in Cost Shifts to Other Payers
Certain treatments for PANDAS/PANS (e.g., IVIG, rituximab, plasma exchange) are generally self-funded
when there is no coverage and there may be some opportunity for enrollees without coverage to seek
help via grant or loan programs through private organizations. A small number of Medi-Cal enrollees may
be able to obtain assistance from California’s Children’s Services (CCS), but CHBRP is unable to
estimate the exact number due to the medical review criteria necessary for CCS eligibility. In California,
unreimbursed medical expenses are income tax deductible, following the federal deductibility threshold.
CHBRP is unable to provide a quantifiable estimate of shifts from private grant and loan funding to health
plans and programs postmandate.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 32
Table 4. Baseline Per Member Per Month Premiums and Total Expenditures by Market Segment, California, 2024
DMHC-Regulated
CDI-Regulated
Commercial Plans (by Market) (a)
Publicly Funded Plans
Commercial Plans (by Market) (a)
Medi-Cal (Excludes
COHS) (c)
Large Group
Small
Group
Individual
CalPER
S (b)
Under 65
65+
Large
Group
Small
Group
Individual
TOTAL
Enrollee counts
Total enrollees in
plans/policies
subject to state
mandates (d)
7,780,000
2,212,000
2,618,000
882,000
8,043,000
774,000
371,000
35,000
127,000
22,842,000
Total enrollees in
plans/policies
subject to AB 907
7,780,000
2,212,000
2,618,000
882,000
8,043,000
774,000
371,000
35,000
127,000
22,842,000
Premium costs
Average portion of
premium paid by
employer (e)
$473.17
$417.10
$0.00
$581.85
$254.61
$543.16
$490.57
$517.32
$0.00
$93,424,638,000
Average portion of
premium paid by
enrollee
$122.17
$180.13
$645.33
$113.49
$0.00
$0.00
$180.61
$168.99
$626.90
$39,493,007,000
Total premium
$595.34
$597.23
$645.33
$695.34
$254.61
$543.16
$671.18
$686.31
$626.90
$132,917,645,000
Enrollee expenses
Cost sharing for
covered benefits
(deductibles,
copays, etc.)
$40.98
$127.06
$168.73
$49.17
$0.00
$0.00
$99.22
$184.48
$208.51
$13,857,141,000
Expenses for
noncovered
benefits (f)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0
Total
expenditures
$636.33
$724.29
$814.06
$744.50
$254.61
$543.16
$770.40
$870.80
$835.40
$146,774,786,000
Source: California Health Benefits Review Program, 2023.
Notes: (a) Includes enrollees with grandfathered and nongrandfathered health insurance acquired outside or through Covered California (the state’s health insurance marketplace).

Analysis of California Assembly Bill 907
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(b) Includes only CalPERS enrollees in DMHC-regulated plans. Approximately 51.1% are state retirees, state employees, or their dependents. About one in five of these enrollees has a
pharmacy benefit not subject to DMHC.
55
CHBRP has projected no impact for those enrollees. However, CalPERS could, postmandate, require equivalent coverage for all its members (which
could increase the total impact on CalPERS).
(c) Includes only Medi-Cal beneficiaries enrolled in DMHC-regulated plans. Includes those who are also Medicare beneficiaries.
(d) Enrollees in plans and policies regulated by DMHC or CDI. Includes those associated with Covered California, CalPERS, or Medi-Cal.
56
(e) In some cases, a union or other organization – or Medi-Cal for its beneficiaries.
(f) Includes only those expenses that are paid directly by enrollees (or other sources) to providers for services related to the mandated benefit that are not covered by insurance at baseline.
This only includes those expenses that will be newly covered, postmandate. Other components of expenditures in this table include all health care services covered by insurance.
Key: CalPERS = California Public Employees’ Retirement System; CDI = California Department of Insurance; COHS = County Organized Health Systems; DMHC = Department of Managed
Health Care.
55
For more detail, see CHBRP’s resource, Estimates of Pharmacy Benefit Coverage in State-Regulated Health Insurance, available at
http://chbrp.org/other_publications/index.php.
56
For more detail, see CHBRP’s resource, Sources of Health Insurance in California, available at http://chbrp.org/other_publications/index.php.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 34
Table 5. Postmandate Per Member Per Month Premiums and Total Expenditures by Market Segment, California, 2024
DMHC-Regulated
.
CDI-Regulated
Commercial Plans (by Market) (a)
Publicly Funded Plans
Commercial Plans (by Market) (a)
Medi-Cal (Excludes COHS) (c)
Large
Group
Small
Group
Individual
CalPERS
(b)
Under 65
65+
Large
Group
Small
Group
Individual
TOTAL
Enrollee counts
Total enrollees in
plans/policies subject to
state mandates (d)
7,780,000
2,212,000
2,618,000
882,000
8,043,000
774,000
371,000
35,000
127,000
22,842,000
Total enrollees in
plans/policies subject to AB
907
7,780,000
2,212,000
2,618,000
882,000
8,043,000
774,000
371,000
35,000
127,000
22,842,000
Premium costs
Average portion of premium
paid by employer (e)
$0.0078
$0.0052
$0.0000
$0.0078
$0.0152
$0.0000
$0.0066
$0.0056
$0.0000
$2,450,000
Average portion of premium
paid by enrollee
$0.0020
$0.0022
$0.0034
$0.0015
$0.0000
$0.0000
$0.0024
$0.0018
$0.0044
$389,000
Total premium
$0.0098
$0.0074
$0.0034
$0.0093
$0.0152
$0.0000
$0.0090
$0.0074
$0.0044
$2,838,000
Enrollee expenses
Cost sharing for covered
benefits (deductibles,
copays, etc.)
$0.0007
$0.0016
$0.0009
$0.0011
$0.0000
$0.0000
$0.0013
$0.0020
$0.0014
$153,000
Expenses for noncovered
benefits (f)
$0.0000
$0.0000
$0.0000
$0.0000
$0.0000
$0.0000
$0.0000
$0.0000
$0.0000
$0
Total expenditures
$0.0105
$0.0090
$0.0043
$0.0104
$0.0152
$0.0000
$0.0104
$0.0094
$0.0058
$2,990,000
Postmandate percent
change
Percent change insured
premiums
0.0016%
0.0012%
0.0005%
0.0013%
0.0060%
0.0000%
0.0013%
0.0011%
0.0007%
0.0021%
Percent change total
expenditures
0.0016%
0.0012%
0.0005%
0.0014%
0.0060%
0.0000%
0.0013%
0.0011%
0.0007%
0.0020%
Source: California Health Benefits Review Program, 2023.
Notes: (a) Includes enrollees with grandfathered and non-grandfathered health insurance acquired outside or through Covered California (the state’s health insurance marketplace).

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 35
(b) Includes only CalPERS enrollees in DMHC-regulated plans. Approximately 51.71are state retirees, state employees, or their dependents. About one in five of these enrollees has a
pharmacy benefit not subject to DMHC.
57
CHBRP has projected no impact for those enrollees. However, CalPERS could, postmandate, require equivalent coverage for all its members (which
could increase the total impact on CalPERS).
(c) Includes only Medi-Cal beneficiaries enrolled in DMHC-regulated plans. Includes those who are also Medicare beneficiaries.
(d) Enrollees in plans and policies regulated by DMHC or CDI. Includes those associated with Covered California, CalPERS, or Medi-Cal.
58
(e) In some cases, a union or other organization – or Medi-Cal for its beneficiaries.
(f) Includes only those expenses that are paid directly by enrollees (or other sources) to providers for services related to the mandated benefit that are not covered by insurance at baseline.
This only includes those expenses that will be newly covered, postmandate. Other components of expenditures in this table include all health care services covered by insurance.
Key: CalPERS = California Public Employees’ Retirement System; CDI = California Department of Insurance; COHS = County Organized Health Systems; DMHC = Department of Managed
Health Care.
57
For more detail, see CHBRP’s resource, Pharmacy Benefit Coverage in State-Regulated Health Insurance, available at http://chbrp.org/other_publications/index.php.
58
For more detail, see CHBRP’s resource, Sources of Health Insurance in California, available at http://chbrp.org/other_publications/index.php.

Analysis of California Assembly Bill 907
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PUBLIC HEALTH IMPACTS
As discussed in the Policy Context section, AB 907 would mandate coverage for the prophylaxis,
diagnosis, and treatment of Pediatric Autoimmune Neuropsychiatric Disorder Associated with
Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS).
Covered treatments must include antibiotics, medication and behavioral therapies to manage
neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous
immunoglobulin therapy).
The public health impact analysis includes estimated impacts in the short term (within 12 months of
implementation) and in the long term (beyond the first 12 months postmandate). This section estimates
the short-term impact
59
of AB 907 on the reduction of symptoms associated with PANDAS/PANS,
potential treatment harms, and financial burden.
Estimated Public Health Outcomes
As presented in Medical Effectiveness, evidence of effective treatments for PANDAS/PANS is lacking. Of
10 treatments evaluated by CHBRP, evidence of effectiveness for 2 treatment types was inconclusive
due to conflicting findings among few studies with small sample sizes. The remaining 8 treatment types
had insufficient evidence to assess their effectiveness in mitigating or eliminating symptoms of these
syndromes.
As presented in the Benefit Coverage, Utilization, and Cost Impacts section, CHBRP estimates that 670
children with insurance subject to AB 907 would have a diagnosis of PANDAS/PANS. Based on
responses from health plans and insurers, baseline coverage for the diagnosis and treatment of
PANDAS/PANS is 100% with the exception of intravenous immunoglobulin (IVIG), rituximab and plasma
exchange, which may be prescribed for moderate to severe cases. In the first 12 months postmandate,
CHBRP projects an increase of 67 doses of rituximab and 469 sessions of IVIG for the enrollees with
moderate and severe cases of PANDAS/PANS (about 442 enrollees or two-thirds of those diagnosed).
See Appendix C for calculations.
Based on the evidence, PANDAS/PANS are rare syndromes, not well-recognized, and subject to
controversy. In the first 12 months postmandate, CHBRP is unable to project a health impact associated
with AB 907 due to the lack of evidence of treatment effectiveness. On an individual basis, enrollees with
severe cases who use IVIG, rituximab, or plasma exchange due to new coverage, may see a reduction or
elimination of symptoms on a case-by-case basis. However, these enrollees may still experience barriers
to accessing IVIG, rituximab, and plasma exchange due to national shortages and/or potential insurance
utilization management requirements. There is insufficient evidence to ascertain whether the potential
harms from these two treatments and plasma exchange outweigh the potential treatment benefits. Due to
the lack of research, CHBRP is unable to include a discussion of disparities among PANDAS/PANS
patients.
In the first year postmandate, the public health impact of AB 907 for the newly covered 670 children with
PANDAS/PANS is unknown due to insufficient and inconclusive evidence regarding the effectiveness of
treatments for PANDAS/PANS. Please note that the absence of evidence is not “evidence of no effect.” It
is possible that an impact – desirable or undesirable – could result, but current evidence is insufficient to
inform an estimate.
Enrollee Financial Burden
Rituximab, IVIG, and plasma exchange are the treatments that would be newly covered under AB 907
with estimated costs of $9,600, $4,300, and $2,100 per session, respectively (see Table 1). CHBRP
59
CHBRP defines short-term impacts as changes occurring within 12 months of bill implementation.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 37
assumes some families paid for these treatments out-of-pocket. However, due to a lack of information
about the type and number of treatment sessions paid for at baseline and unknown effects of utilization
management postmandate, CHBRP is unable to project the impact of AB 907 on out-of-pocket expenses
for previously uncovered treatments.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org 38
LONG-TERM IMPACTS
In this section, CHBRP estimates the long-term impact of AB 907 which CHBRP defines as impacts
occurring beyond the first 12 months after implementation. These estimates are qualitative and based on
the existing evidence available in the literature. CHBRP does not provide quantitative estimates of long-
term impacts because of unknown improvements in clinical care, changes in prices, implementation of
other complementary or conflicting policies, and other unexpected factors.
Long-Term Utilization and Cost Impacts
Utilization Impacts
Utilization of diagnostic tests and treatments for PANDAS/PANS is expected to be similar in the long term
as utilization in the first 12 months postmandate. However, should evidence about the effectiveness of
new diagnostic tests or treatments such as IVIG or rituximab become more conclusive, for example, via
more evidence from larger randomized controlled clinical trials, more physicians may prescribe these
treatments.
Cost Impacts
Cost impacts are expected to also be similar to those projected in the first 12 months postmandate.
Long-Term Public Health Impacts
Some interventions in proposed mandates provide immediate measurable impacts (e.g., maternity service
coverage or acute care treatments), whereas other interventions may take years to make a measurable
impact (e.g., coverage for tobacco cessation or vaccinations). When possible, CHBRP estimates the long-
term effects (beyond 12 months postmandate) to the public’s health that would be attributable to the
mandate, including impacts disparities, premature death, and economic loss.
Due to the dearth of research about PANDAS/PANS, CHBRP finds an unknown health impact of AB 907
over the long term.
It is possible that growing awareness of PANDAS and PANS statewide may increase the number of
children diagnosed and treated, with an unknown, but potentially beneficial effect on child and family
quality of life and school performance.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org A-1
APPENDIX A TEXT OF BILL ANALYZED
The California Assembly Committee on Health requested that CHBRP analyze AB 907, as amended on
March 16, 2023.
AMENDED IN ASSEMBLY MARCH 16, 2023
CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION
ASSEMBLY BILL NO. 907
Introduced by Assembly Member Lowenthal
February 14, 2023
An act to add Section 1367.38 to the Health and Safety Code, and to add Section 10123.38 to the
Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 907, as amended, Lowenthal. Coverage for PANDAS and PANS.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure
and regulation of health care service plans by the Department of Managed Health Care, and makes
a willful violation of the act a crime. Existing law provides for the regulation of health insurers by
the Department of Insurance. Existing law sets forth specified coverage requirements for health
care service plan contracts and health insurance policies, and limits the copayment, coinsurance,
deductible, and other cost sharing that may be imposed for specified health care services.
This bill would require a health care service plan contract or health insurance policy issued,
amended, or renewed on or after January 1, 2024, to provide coverage for the prophylaxis,
diagnosis, and treatment of Pediatric Autoimmune Neuropsychiatric Disorder Associated with
Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome
(PANS) that is prescribed or ordered by a provider. The bill would prohibit coverage for PANDAS
and PANS from being subject to a copayment, coinsurance, deductible, or other cost sharing that
is greater than that applied to other similar benefits. The bill would prohibit a plan or insurer from
denying or delaying coverage for medically necessary treatment of PANDAS or
PANS solely therapies because the enrollee or insured previously received treatment for
PANDAS or PANS or has been was diagnosed with or received treatment for the condition under
a different diagnostic name. Because a willful violation of these provisions by a health care service
plan would be a crime, the bill would impose a state-mandated local program.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org A-2
The California Constitution requires the state to reimburse local agencies and school districts for
certain costs mandated by the state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: majority Appropriation: no Fiscal Committee: yes Local Program: yes
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.38 is added to the Health and Safety Code, to read:
1367.38. (a) A health care service plan contract issued, amended, or renewed on or after January
1, 2024, shall provide coverage for the prophylaxis, diagnosis, and treatment of Pediatric
Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and
Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) that is prescribed or ordered by a
provider. Treatment for PANDAS and PANS that shall be covered includes antibiotics, medication
and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines,
plasma exchange, and intravenous immunoglobulin therapy.
(b) Coverage for PANDAS and PANS shall not be subject to a copayment, coinsurance,
deductible, or other cost sharing that is greater than that applied to other similar benefits provided
by the contract.
(c) (1) Coverage Any required authorization for PANDAS and PANS prophylaxis, diagnosis, or
treatment shall be provided in a timely manner that is appropriate for the severity of an enrollee’s
condition pursuant to Section 1367.03.
(2) A health care service plan shall not deny or delay coverage for medically necessary treatment
of PANDAS or PANS solely therapies because the enrollee previously received treatment,
including the same or similar treatment, for PANDAS or PANS PANS, or because the
enrollee has been was diagnosed with or received treatment for their condition under a different
diagnostic name, including autoimmune encephalopathy.
(3)Coverage for any form of medically necessary treatment shall not be limited over a lifetime
of an enrollee or by contract period.
(4)This section does not prohibit a plan from requesting treatment notes and anticipated
duration of treatment and outcomes from a provider.
(3) A health care service plan shall not limit coverage of immunomodulating therapies for
PANDAS or PANS in a manner that is inconsistent with the treatment recommendations
pursuant to subdivision (d), and shall not require a trial of therapies that treat only
neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies
pursuant to this section.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org A-3
(d) Coverage for PANDAS and PANS shall adhere to the treatment recommendations developed
by a consortium of medical professionals convened to research, identify, and publish best
practice clinical practice guidelines and evidence-based standards for the diagnosis and treatment
of those disorders that are accessible to providers and are based on evidence of positive patient
outcomes. disorders.
(e) For billing and diagnostic purposes, PANDAS and PANS shall be coded as autoimmune
encephalitis until the American Medical Association and the federal Centers for Medicare and
Medicaid Services create and assign a specific code or codes for PANDAS and PANS. After the
creation of that code or codes, PANDAS and PANS may be coded as autoimmune encephalitis,
PANDAS, or PANS. If PANDAS or PANS is known by a different common name in the future,
it may be coded under that name and this section shall apply to that disorder or syndrome.
(f) This section does not apply to a specialized health care service plan contract that does not
cover an essential health benefit, as defined in Section 1367.005, or a Medicare supplement policy.
SEC. 2. Section 10123.38 is added to the Insurance Code, to read:
10123.38. (a) A health insurance policy issued, amended, or renewed on or after January 1, 2024,
shall provide coverage for the prophylaxis, diagnosis, and treatment of Pediatric Autoimmune
Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric
Acute-onset Neuropsychiatric Syndrome (PANS) that is prescribed or ordered by a provider.
Treatment for PANDAS and PANS that shall be covered includes antibiotics, medication and
behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines,
plasma exchange, and intravenous immunoglobulin therapy.
(b) Coverage for PANDAS and PANS shall not be subject to a copayment, coinsurance,
deductible, or other cost sharing that is greater than that applied to other similar benefits provided
by the policy.
(c) (1) Coverage Any required authorization for PANDAS and PANS prophylaxis, diagnosis, or
treatment shall be provided in a timely manner that is appropriate for the severity of an insured’s
condition pursuant to Section 10133.54.
(2) A health insurer shall not deny or delay coverage for medically necessary treatment
of PANDAS or PANS solely therapies because the insured previously received treatment,
including the same or similar treatment, for PANDAS or PANS PANS, or because the
insured has been was diagnosed with or received treatment for their condition under a different
diagnostic name, including autoimmune encephalopathy.
(3)Coverage for any form of medically necessary treatment shall not be limited over a lifetime
of an insured or by policy period.
(4)This section does not prohibit an insurer from requesting treatment notes and anticipated
duration of treatment and outcomes from a provider.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org A-4
(3) A health insurer shall not limit coverage of immunomodulating therapies for PANDAS or
PANS in a manner that is inconsistent with the treatment recommendations pursuant to
subdivision (d), and shall not require a trial of therapies that treat only neuropsychiatric
symptoms before authorizing coverage of immunomodulating therapies pursuant to this section.
(d) Coverage for PANDAS and PANS shall adhere to the treatment recommendations developed
by a consortium of medical professionals convened to research, identify, and publish best
practice clinical practice guidelines and evidence-based standards for the diagnosis and treatment
of those disorders that are accessible to providers and are based on evidence of positive patient
outcomes. disorders.
(e) For billing and diagnostic purposes, PANDAS and PANS shall be coded as autoimmune
encephalitis until the American Medical Association and the federal Centers for Medicare and
Medicaid Services create and assign a specific code or codes for PANDAS and PANS. After the
creation of that code or codes, PANDAS and PANS may be coded as autoimmune encephalitis,
PANDAS, or PANS. If PANDAS or PANS is known by a different common name in the future,
it may be coded under that name and this section shall apply to that disorder or syndrome.
(f) This section does not apply to a specialized health insurance policy that does not cover an
essential health benefit, as defined in Section 10112.27, or a Medicare supplement policy.
SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the
California Constitution because the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or infraction, eliminates a crime or
infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556
of the Government Code, or changes the definition of a crime within the meaning of Section 6 of
Article XIII B of the California Constitution.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org B-1
APPENDIX B LITERATURE REVIEW METHODS
This appendix describes methods used in the literature review conducted for this report. A discussion of
CHBRP’s system for medical effectiveness grading evidence follows.
Studies of the effects of antibiotics, psychotropics, behavioral therapy, plasma exchange, intravenous
immunoglobulin (IVIG) therapy and other immunomodulating medications were identified through
searches of PubMed, CINAHL Complete, PsycInfo, Scopus, Web of Science Core Collection, EconLit,
Business Source Complete. The search was limited to abstracts of studies published in English, persons
diagnosed with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections
(PANDAS) and/or Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS). The search was limited to
studies published from 2017 to present, CHBRP relied on a systematic review published in 2018 for
findings from studies published prior to 2017.
Reviewers screened the title and abstract of each citation retrieved by the literature search to determine
eligibility for inclusion. The reviewers acquired the full text of articles that were deemed eligible for
inclusion in the review and reapplied the initial eligibility criteria.
Medical Effectiveness Review
The medical effectiveness literature review returned abstracts for 129 articles, of which 14 were reviewed
for inclusion in this report. A total of 11 studies were included in the medical effectiveness review for AB
907.
Medical Effectiveness Evidence Grading System
In making a “call” for each outcome measure, the medical effectiveness lead and the content expert
consider the number of studies as well the strength of the evidence. Further information about the criteria
CHBRP uses to evaluate evidence of medical effectiveness can be found in CHBRP’s Medical
Effectiveness Analysis Research Approach.
60
To grade the evidence for each outcome measured, the
team uses a grading system that has the following categories:
• Research design;
• Statistical significance;
• Direction of effect;
• Size of effect; and
• Generalizability of findings.
The grading system also contains an overall conclusion that encompasses findings in these five domains.
The conclusion is a statement that captures the strength and consistency of the evidence of an
intervention’s effect on an outcome. The following terms are used to characterize the body of evidence
regarding an outcome:
• Clear and convincing evidence;
• Preponderance of evidence;
• Limited evidence;
• Inconclusive evidence; and
• Insufficient evidence.
60
Available at: www.chbrp.org/about/analysis-methodology/medical-effectiveness-analysis.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org B-2
A grade of clear and convincing evidence indicates that there are multiple studies of a treatment and that
the large majority of studies are of high quality and consistently find that the treatment is either effective
or not effective.
A grade of preponderance of evidence indicates that the majority of the studies reviewed are consistent in
their findings that treatment is either effective or not effective.
A grade of limited evidence indicates that the studies had limited generalizability to the population of
interest and/or the studies had a fatal flaw in research design or implementation.
A grade of inconclusive evidence indicates that although some studies included in the medical
effectiveness review find that a treatment is effective, a similar number of studies of equal quality suggest
the treatment is not effective.
A grade of insufficient evidence indicates that there is not enough evidence available to know whether or
not a treatment is effective, either because there are too few studies of the treatment or because the
available studies are not of high quality. It does not indicate that a treatment is not effective.

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org C-1
APPENDIX C COST IMPACT ANALYSIS: DATA SOURCES,
CAVEATS, AND ASSUMPTIONS
With the assistance of CHBRP’s contracted actuarial firm, Milliman, Inc, the cost analysis presented in
this report was prepared by the faculty and researchers connected to CHBRP’s Task Force with expertise
in health economics.
61
Information on the generally used data sources and estimation methods, as well
as caveats and assumptions generally applicable to CHBRP’s cost impacts analyses are available at
CHBRP’s website.
62
This appendix describes analysis-specific data sources, estimation methods, caveats, and assumptions
used in preparing this cost impact analysis.
Analysis-Specific Data Sources
Current coverage of tests, treatments, and services for commercial enrollees was determined by a survey
of the largest (by enrollment) providers of health insurance in California. Responses to this survey
represent 82% of commercial enrollees with health insurance that can be subject to state benefit
mandates. In addition, CalPERS, DHCS, and the four largest (by enrollment) DMHC-regulated plans
enrolling Medi-Cal beneficiaries were queried regarding related benefit coverage. As necessary, CHBRP
extrapolated from responses of similarly situated plans/policies.
For this analysis, CHBRP relied on CPT® codes to identify relevant services. CPT copyright 2023
American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors
and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical
services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered
trademark of the American Medical Association.
Detailed Cost Notes Regarding Analysis-Specific Caveats and Assumptions
The analytic approach and key assumptions are determined by the subject matter and language of the bill
being analyzed. As a result, analytic approaches may differ between topically similar analyses, and
therefore the approach and findings may not be directly comparable.
• CHBRP used Milliman’s 2021 Consolidated Health Cost Guidelines Sources Database (CHSD) to
estimate annual average cost for PANDAS/PANS diagnostic tests and treatments in 2024.
CHBRP calculated the baseline average cost for PANDAS/PANS diagnostic tests, prescription
medications, and services such as IVIG, plasma exchange, and rituximab per unit by dividing the
total allowed dollars observed in the data for the selected treatments and services by the total
units observed in the data for the selected treatments and services. CHBRP assumed an annual
increase in costs over time between 2.85% and 4.50%, depending on the type of service.
• Estimated annual average cost for PANDAS/PANS diagnostic tests and treatments in 2024 were
calculated using an average of commercial and Medi-Cal claims data.
• Based on the literature and consultations with a clinical expert, CHBRP assumed that new onset
cases of PANDAS/PANS primarily occur in children 17 years of age and younger.
• The prevalence of PANDAS/PANS has not been well described in the literature. CHBRP
estimated the prevalence of PANDAS/PANS using a combination of estimates from the literature
and consultation with a clinical experts. CHBRP assumed a prevalence of PANDAS/PANS of
61
CHBRP’s authorizing statute, available at https://chbrp.org/about_chbrp/index.php, requires that CHBRP use a
certified actuary or “other person with relevant knowledge and expertise” to determine financial impact.
62
See method documents posted at www.chbrp.org/about/analysis-methodology/cost-impact-analysis; in particular,
see Cost Analyses: Data Sources, Caveats, and Assumptions.

Analysis of California Assembly Bill 907
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1/10,000 (Kronenberg and Shouldice, 2019). Using this prevalence, and estimating that about 6.7
million enrollees 17 years of age and younger are subject to the benefit mandate, CHBRP
estimated that 670 children 17 years of age and younger are diagnosed with PANDAS/PANS
annually.
• To estimate the diagnostic test utilization, CHBRP assumed a 1-year incidence of onset OCD of
0.7% (Valleni-Basile et al., 1996). CHBRP assumed that of these new-onset cases, 33% had
severe OCD, for which tests for PANDAS/PANS would be recommended (Gilbert et al., 2018).
CHBRP estimated the number of children 12 years of age and younger with utilization of
diagnostic tests for PANDAS/PANS by multiplying the total number of enrollees ages 12 and
younger subject to the benefit mandate by the 1-year incidence of onset OCD (0.7%) and then
multiplying this number by 0.333.
• CHBRP reviewed CHSD data for patients diagnosed with PANDAS/PANS using logic outlined in
Table 6. CHBRP estimated utilization amounts for three different severity levels (mild, moderate,
severe) based on discussions with content experts and a review of literature.
Table 6. ICD-10 Codes Used to Identify PANDAS/PANS Service Utilization
Condition
How Identified
PANDAS
Must include ICD-10 code: D89.89.
Then also include one of the following: OCD, tic disorder, panic disorder,
depression, eating disorders
PANS
ICD-10 code: G04.81 (for autoimmune encephalitis)
Then also include one of the following: OCD, tic disorder, panic disorder,
depression, eating disorders
OCD
F42.2, F42.8, F42.9, F60.5
Tic disorder
F95.0-F95.9
Panic disorder
F41.0-F41.3, F41.8, F41.9
Depression
F32.0-F32.5, F33.0-F33.5
Eating disorders
F50.0-F50.9
Source: California Health Benefits Review Program, 2023.
• The following table shows the assumed distribution of PANDAS/PANS cases between mild,
moderate, and severe. This assumption was made based on informal conversations with
PANDAS/PANS clinical experts.
Table 7. Distribution of PANDAS/PANS Severity
Severity
Distribution
Mild
33.33%
Moderate
33.33%
Severe
33.33%
Source: California Health Benefits Review Program, 2023; informal discussions with PANDAS/PANS clinical expert.

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• Table 8 identifies all services included in the estimated treatment plans by severity level for
PANDAS/PANS. The table shows the Table 1 category for each service/treatment, and the
language included in the bill. Finally, it also shows how the service/treatment is identified, either
with a national drug code (NDC) for prescription drugs, or by CPT codes. CHBRP only modeled
diagnostics and treatments that are included in the PANDAS/PANS guidelines discussed earlier
in the report. There is one exception – the prescription drug mycophenolate mofetil is in the
guidelines but was excluded from the analysis based on the recommendations of clinical experts.
Note that prescription drugs contain many NDCs. For simplicity, CHBRP chose one common
generic drug NDC to use for each drug category. In practice, there are many suitable prescription
drug options that could be prescribed from these drug categories.
• In Table 9, the utilization numbers represent the assumed annual utilization per enrollee with
PANDAS/PANS, with the following exceptions.
o The utilization for IVIG is assumed to be dampened by a factor of 0.2. This is due to a
variety of issues that will limit the utilization of IVIG, as discussed more fully in the Benefit
Coverage, Utilization, and Cost Impacts section.
o The utilization for all diagnostic tests is not per enrollee with PANDAS/PANS, but rather
per enrollee that undergoes diagnostic testing to determine if the child has PANDAS/PANS.
CHBRP estimated that for every PANDAS/PANS diagnosis, there are 22 children who are
tested for it who do not receive a diagnosis for it.
• For each Table 1 category, CHBRP took the average cost per procedure for all treatments and
services aggregated within the category.
Table 8. Services Included in Estimated Treatment Plans by Severity Level
Assumed Annual Utilization
by Severity
Language in Bill
Services/
Treatments
Table 1
Category
How Identified
Mild
Moderate
Severe
Antibiotics
Amoxicillin
Prescription
medication
NDC: 65862001705
1/2
month
1/2 month
1/2 month
Immunomodulating
medications
Corticosteroids
Prescription
medication
NDC: 00054001825
2
months
2 months
2 months
Immunomodulating
medications
Nonsteroidal anti-
inflammatory
drugs
Prescription
medication
NDC: 64380080707
2
months
2 months
2 months
Medication therapies to
manage
neuropsychiatric
symptoms of PANS
Selective
serotonin uptake
inhibitors
Prescription
medication
NDC: 50111064801
None
2 months
12 months
Medication therapies to
manage
neuropsychiatric
symptoms of PANS
Benzodiazepines
Prescription
medication
NDC: 65862067799
None
2 months
12 months
Medication therapies to
manage
neuropsychiatric
symptoms of PANS
Antipsychotics
Prescription
medication
NDC: 55111025660
None
2 months
12 months
Behavioral health
therapies to manage
neuropsychiatric
symptoms of PANS
Cognitive
behavioral
therapy
Psychology
visits
CPT Codes: 90791,
90832, 90834, 90837
None
30 visits, 1
hr each
30 visits, 1
hr each
Plasma exchange
Plasma exchange
Plasma
exchange
CPT Codes: 36514,
36516
None
None
None
Intravenous
immunoglobulin therapy
Intravenous
immunoglobulin
therapy
IVIG infusions
CPT Codes for
administration: 96365,
96366, 96368
J-Code for drug cost:
J1459, J1554, J1556,
J1557, J1561, J1566,
None
1 infusion
9 infusions

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J1568,J1569, J1572,
J1599
Immunomodulating
medications
Rituximab
Immunomodula
ting infusion
therapy –
rituximab
NDC:
50242005110,
50242005121,
50242005306,
50242010801,
50242010901
None
None
3 infusions
Diagnostics
Group A Beta-
Hemolytic
Streptococcus
with throat culture
Diagnostics
CPT: 87081
2 tests
2 tests
2 tests
Diagnostics
ASO (blood test)
Diagnostics
CPT: 86060
1 test
1 test
1 test
Diagnostics
AntiD-Nase-B
Diagnostics
CPT: 86215
1 test
1 test
1 test
Diagnostics
CBC with
differential
Diagnostics
CPT: 85025
1 test
1 test
1 test
Diagnostics
Antinuclear with
antibody titers
Diagnostics
CPT: 86038
1 test
1 test
1 test
Diagnostics
Quantitative
immunoglobulins
Diagnostics
CPT: 82784, 82785
1 test
1 test
1 test
Diagnostics
Mycoplasma
pneumoniae,
DNA PCR
Diagnostics
CPT: 87581
1 test
1 test
1 test
Diagnostics
Mycoplasma
pneumoniae,
antibodies, IgG,
IgM
Diagnostics
CPT: 86738
1 test
1 test
1 test
Source: California Health Benefits Review Program, 2023.
Based on the average cost calculated from the CHSD data and the utilization estimated by the content
expert, CHBRP developed average annual costs of all PANDAS/PANS diagnosis and treatment services,
per PANDAS/PANS enrollee pre- and postmandate. CHBRP assumed that the services are subject to an
average cost-sharing of 11.8% for all plans that are not Medi-Cal, and assumed no cost sharing for the
Medi-Cal plans. CHBRP did not model self-pay for any of these services pre-mandate. The baseline and
postmandate coverage assumptions were based on the carrier surveys, and are shown in the table
below.
Table 9. Coverage Assumptions of Treatments
Table 1 Category
Coverage at
Baseline
Coverage
Postmandate
Diagnostics
100%
100%
Prescription medication
100%
100%
Psychology visits
100%
100%
Immunomodulating infusion therapy – IVIG session
0%
100%
Immunomodulating infusion therapy - rituximab
0%
100%
Plasma exchange session
0%
100%
Source: California Health Benefits Review Program, 2023.
Note that while CHBRP included the average cost of plasma exchange in Table 1, CHBRP does not
expect the change in coverage for this service to result in any additional costs to the DMHC-regulated
plan or CDI-regulated policy.

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CHBRP did not include the use of MRI or EEG tests when considering diagnostic tests for
PANDAS/PANS, as these are typically used to diagnose or rule out other conditions (PANDAS
Physicians Network 2023).
Determining Public Demand for the Proposed Mandate
CHBRP reviews public demand for benefits by comparing the benefits provided by self-insured health
plans or policies (which are not regulated by the DMHC or CDI and therefore not subject to state-level
mandates) with the benefits that are provided by plans or policies that would be subject to the mandate.
Among publicly funded self-insured health insurance policies, the preferred provider organization (PPO)
plans offered by CalPERS have the largest number of enrollees. The CalPERS PPOs currently provide
benefit coverage similar to what is available through group health insurance plans and policies that would
be subject to the mandate.
To further investigate public demand, CHBRP used the bill-specific coverage survey to ask plans and
insurers who act as third-party administrators for (non-CalPERS) self-insured group health insurance
programs whether the relevant benefit coverage differed from what is offered in group market plans or
policies that would be subject to the mandate. The responses indicated that there were no substantive
differences.
Second-Year Impacts on Benefit Coverage, Utilization, and Cost
CHBRP has considered whether continued implementation during the second year of the benefit
coverage requirements of AB 907 would have a substantially different impact on utilization of either the
tests, treatments, or services for which coverage was directly addressed, the utilization of any indirectly
affected utilization, or both. CHBRP reviewed the literature and consulted content experts about the
possibility of varied second-year impacts and determined the second year’s impacts of AB 907 would be
substantially the same as the impacts in the first year (see Table 1). Minor changes to utilization and
expenditures are due to population changes between the first year postmandate and the second year
postmandate.

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Current as of April 20, 2023 www.chbrp.org
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CALIFORNIA HEALTH BENEFITS REVIEW PROGRAM
COMMITTEES AND STAFF
A group of faculty, researchers, and staff complete the analysis that informs California Health Benefits
Review Program (CHBRP) reports. The CHBRP Faculty Task Force comprises rotating senior faculty
from University of California (UC) campuses. In addition to these representatives, there are other ongoing
researchers and analysts who are Task Force Contributors to CHBRP from UC that conduct much of
the analysis. The CHBRP staff coordinates the efforts of the Faculty Task Force, works with Task Force
members in preparing parts of the analysis, and manages all external communications, including those
with the California Legislature. As required by CHBRP’s authorizing legislation, UC contracts with a
certified actuary, Milliman, to assist in assessing the financial impact of each legislative proposal
mandating or repealing a health insurance benefit.
The National Advisory Council provides expert reviews of draft analyses and offers general guidance
on the program to CHBRP staff and the Faculty Task Force. CHBRP is grateful for the valuable
assistance of its National Advisory Council. CHBRP assumes full responsibility for the report and the
accuracy of its contents.
Faculty Task Force
Paul Brown, PhD, University of California, Merced
Timothy T. Brown, PhD, University of California, Berkeley
Janet Coffman, MA, MPP, PhD, Vice Chair for Medical Effectiveness, University of California, San
Francisco
Todd Gilmer, PhD, University of California, San Diego
Sylvia Guendelman, PhD, LCSW, University of California, Berkeley
Elizabeth Magnan, MD, PhD, Vice Chair for Public Health, University of California, Davis
Sara McMenamin, PhD, Vice Chair for Medical Effectiveness and Public Health, University of California,
San Diego
Joy Melnikow, MD, MPH, University of California, Davis
Aimee Moulin, MD, University of California, Davis
Jack Needleman, PhD, University of California, Los Angeles
Mark A. Peterson, PhD, University of California, Los Angeles
Nadereh Pourat, PhD, Vice Chair for Cost, University of California, Los Angeles
Dylan Roby, PhD, University of California, Irvine
Marilyn Stebbins, PharmD, University of California, San Francisco
Jonathan H. Watanabe, PharmD, MS, PhD, University of California, Irvine
Task Force Contributors
Bethney Bonilla, MA, University of California, Davis
Danielle Casteel, MA, University of California, San Diego
Shana Charles, PhD, MPP, University of California, Los Angeles, and California State University,
Fullerton
Margaret Fix, MPH, University of California, San Francisco
Naomi Hillery, MPH, University of California, San Diego
Jeffrey Hoch, PhD, University of California, Davis
Julia Huerta, BSN, RN, MPH, University of California, Davis
Michelle Keller, PhD, MPH, University of California, Los Angeles
Jacqueline Miller, University of California, San Francisco
Marykate Miller, MS, University of California, Davis
Katrine Padilla, MPP, University of California, Davis
Amy Quan, University of California, San Francisco
Dominique Ritley, MPH, University of California, Davis

Analysis of California Assembly Bill 907
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Emily Shen, University of California, San Francisco
Riti Shimkhada, PhD, University of California, Los Angeles
Meghan Soulsby Weyrich, MPH, University of California, Davis
Steven Tally, PhD, University of California, San Diego
Sara Yoeun, MPH, University of California, San Diego
National Advisory Council
Lauren LeRoy, PhD, Strategic Advisor, L. LeRoy Strategies, Chair
Stuart H. Altman, PhD, Professor of National Health Policy, Brandeis University, Waltham, MA
Deborah Chollet, PhD, Senior Fellow, Mathematica Policy Research, Washington, DC
Allen D. Feezor, Former Deputy Secretary for Health Services, North Carolina Department of Health and
Human Services, Raleigh, NC
Charles “Chip” Kahn, MPH, President and CEO, Federation of American Hospitals, Washington, DC
Jeffrey Lerner, PhD, President Emeritus, ECRI Institute Headquarters, Plymouth Meeting, PA; Adjunct
Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania
Donald E. Metz, Executive Editor, Health Affairs, Bethesda, MD
Dolores Mitchell, (Retired) Executive Director, Group Insurance Commission, Boston, MA
Marilyn Moon, PhD, Senior Fellow, Retired, American Institutes for Research, Washington, DC
Carolyn Pare, (Retired) President and CEO, Minnesota Health Action Group, Bloomington, MN
Richard Roberts, MD, JD, Professor Emeritus of Family Medicine, University of Wisconsin-Madison,
Madison, WI
Alan Weil, JD, MPP, Editor-in-Chief, Health Affairs, Bethesda, MD
CHBRP Staff
Garen Corbett, MS, Director
John Lewis, MPA, Associate Director
Adara Citron, MPH, Principal Policy Analyst
An-Chi Tsou, PhD, Principal Policy Analyst
Victor Garibay, Policy Associate
Karen Shore, PhD, Contractor*
*Independent Contractor working with CHBRP to support analyses and other projects.
CHBRP is an independent program administered and housed by the University of California, Berkeley,
under the Office of the Vice Chancellor for Research.
California Health Benefits Review Program
MC 3116
Berkeley, CA 94720-3116
info@chbrp.org
(510) 664-5306

Analysis of California Assembly Bill 907
Current as of April 20, 2023 www.chbrp.org
ACKNOWLEDGMENTS
CHBRP gratefully acknowledges the efforts of the team contributing to this analysis:
Joy Melnikow, MD, MPH, Marykate Miller, MS, of the University of California, Davis, prepared the medical
effectiveness analysis. Stephen L. Clancy, MLS, of the University of California, Irvine, conducted the
literature search. Joy Melnikow, MD, MPH, Dominique Ritley, MPH, and Katrine Padilla, MPP, all of the
University of California, Davis, prepared the public health impact analysis. Michelle Keller, PhD, MPH, of
the University of California, Los Angeles, prepared the cost impact analysis. Matt Schoonmaker, FSA,
MAAA, provided actuarial analysis. An-Chi Tsou, PhD, of CHBRP staff prepared the Policy Context and
synthesized the individual sections into a single report. A subcommittee of CHBRP’s National Advisory
Council (see previous page of this report) and a member(s) of the CHBRP Faculty Task Force, Nadereh
Pourat, PhD, all of the University of California, Los Angeles, and Elizabeth Magnan, MD, PhD, of the
University of California, Davis, reviewed the analysis for its accuracy, completeness, clarity, and
responsiveness to the Legislature’s request.
CHBRP assumes full responsibility for the report and the accuracy of its contents. All CHBRP bill
analyses and other publications are available at www.chbrp.org.
Garen Corbett, MS
Director
Please direct any questions concerning this document to: California Health Benefits Review Program; MC
3116; Berkeley, CA 94720-3116, info@chbrp.org, or www.chbrp.org