Dry Eye Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for Tyrvaya. The patient has chronic bilateral dry eye disease that developed following cataract surgery, a clinical condition associated with disruption of tear film homeostasis and corneal sensory nerve function.The patient’s symptoms include fluctuating vision, ocular discomfort, pressure, and episodic migraine-like sensations consistent with tear film instability and a sensory component of dry eye disease. Conservative therapies, including warm compresses, lubricating eye drops, and omega-3 supplementation, have been insufficient to control symptoms.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and overage for brand name Lotemax 0.5% ophthalmic suspension. Medical literature note that dry eye disease is a common ocular condition that may be effectively treated by topical corticosteroids. The authors further note that loteprednol (brand name Lotemax) is safe and well tolerated, with minimal effects on intraocular pressure. Loteprednol is a type of synthetic steroid with advantages over standard steroids, such as dexamethasone and prednisolone, as it acts mostly on the surface of the eye and does not lead to cataract development, which may be a side effect of standard steroids. In this case, the records noted that the patient had tried both the generic and brand formulations of loteprednol, and reported that her symptoms were better using the brand formulation.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for VEVYE (cyclosporine ophthalmic solution). Dry eye disease is a complex, multifactorial condition characterized by tear film instability, ocular surface inflammation, neurosensory dysfunction, and damage. It is a cyclical, multifactorial disease in which identifying and addressing the underlying cause is essential to breaking the cycle and restoring ocular surface homeostasis. This requires a personalized treatment plan. Therapeutic options include various strengths of cyclosporine, cholinergic agonists, semi fluorinated alkanes, corticosteroids, and procedural interventions such as intense pulsed light therapy or thermal pulsation.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cequa 0.09% eye solution. Findings: In a randomized, double-masked, placebo-controlled trial of patients with an eye dryness score (EDS) of at least 40, a study concluded that lifitegrast, the active ingredient in Xiidra, significantly improved symptoms of eye dryness versus placebo, as measured by EDS. In a multicenter, randomized, double-masked, vehicle controlled study, it was found that 20.5% of study participants receiving Cequa 0.09% achieved a greater than or equal to ten mm increase in their Schirmer’s tear score, compared to 11.3% of study participants receiving vehicle, and that Cequa 0.09% significantly improved total conjunctival staining over vehicle at week 12. However, these results have so far not been replicated and independently verified by other studies.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving dry eye disease, then check the rights and deadlines that apply to your plan.