Epilepsy Seizures Migraine SD denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that a patient has requested authorization and coverage for Zepbound.The medical records show that the patient has obesity with multiple high‑risk cardiometabolic comorbidities, including hypertension, hyperlipidemia, and obstructive sleep apnea (OSA). The patient’s apnea/hypopnea index (AHI) of 20 events per hour, along with significant nocturnal hypoxemia, meets criteria for moderate OSA. OSA can contribute to persistent symptoms such as daytime sleepiness, impaired sleep architecture, and ongoing cardiovascular and neurocognitive risks. The patient previously attempted continuous positive airway pressure (CPAP) therapy but was unable to tolerate the mask. In such cases, Zepbound provides a complementary therapeutic approach by addressing physiological mechanisms that CPAP alone does not modify.

Findings: The physician reviewer found that a patient has requested authorization and coverage for Zepbound. The U.S. Food and Drug Administration (FDA) has approved Zepbound (tirzepatide) for weight management in adults with obesity (BMI > 30 kg/m²) or overweight adults (BMI 27–29.9 kg/m²) with at least one weight‑related comorbidity, to be used alongside reduced‑calorie intake and increased physical activity. Clinical trials demonstrated that tirzepatide produces substantial and sustained weight loss compared with placebo at 52 and 72 weeks. Zepbound is also FDA‑approved for overweight or obese patients with moderate‑to‑severe obstructive sleep apnea (OSA). Because excess weight is a major contributor to both the risk and severity of OSA, weight reduction is a standard component of management.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested authorization and coverage for Wakix. The American Academy of Sleep Medicine (AASM) clinical practice guidelines note that treatment of idiopathic hypersomnia begins with confirmation of the diagnosis and exclusion of other causes of excessive daytime sleepiness. Once confirmed, pharmacologic therapy is recommended, with modafinil strongly supported as a first‑line option. Wakix is approved by the U.S. Food and Drug Administration (FDA) for the treatment of excessive daytime sleepiness or cataplexy in narcolepsy but is not FDA‑approved for idiopathic hypersomnia. Per the medical records, the patient has a diagnosis of idiopathic hypersomnia and is taking modafinil at a dosage that has not been optimized.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for brand-name Keppra XR 500 mg tablets.The records indicate that the patient has a history of seizures. The patient has previously been treated with Depakote and Tegretol without adequate control and has remained stable for many years on Keppra. Keppra is approved for the treatment of seizure disorders. However, available evidence demonstrates that generic levetiracetam is bioequivalent to brand-name Keppra, and switching between brand and generic formulations does not result in clinically significant differences in seizure control or adverse effects.

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 epilepsy seizures migraine sd, then check the rights and deadlines that apply to your plan.