Gout denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Krystexxa. A study noted that the current guidelines recommend having a uric acid level <6 ml/dL. In patients who have had reactions to allopurinol, “If allopurinol toxicity does occur, alternative urate lowering treatments may be employed. As discussed in proposition 2, non&#8208;pharmacological approaches such as education, weight loss, reducing alcohol consumption, and dietary modification should always be considered. However, if urate lowering drugs are required, the current alternatives are other xanthine oxidase inhibitors or uricosuric agents.

The patient is a 43-year-old male with recurrent gout for the past two years. He had been appropriately referred to a rheumatologist for management of his gout. Once the patient’s acute symptoms were controlled, the Health Plan determined the patient’s PCP could manage the patient further. Subsequently, a change in the patient’s medication resulted in a recurrent acute attack of gout. The Health Plan indicates continued care with a rheumatologist for management of the patient’s gout is not medically necessary.Of all rheumatologic conditions, gout may be the most eminently and effectively manageable. With appropriate treatment, and in the absence of allergy to Allopurinol, gout should be suppressed well enough that no further acute episodes occur in a given patient.It can be very difficult to effectively manage gout as a chronic recurring condition.

Where the denial was upheld

A 65-year-old male enrollee has requested reimbursement for emergency services. Findings: The physician reviewer found that The patient is a 65-year-old male who sustained an initial fall and broke his neck and sustained right-sided weakness. He was discharged from an acute care hospital three days later and was admitted to a skilled nursing facility (SNF) the following day with a cervical collar in place. On the day of admission to the SNF or the following day the patient reportedly fell to the floor in the bathroom after slipping off the toilet. He reported no loss of consciousness or complaint of new neck pain. He was taken by ambulance from the SNF to the Emergency Department.

Nature of Statutory Criteria/ Case Summary: At issue is whether Norco is medically necessary to treat the patient’s medical condition. This is a patient that experiences chronic pain and arthritis in the back, hips and knees, fibromyalgia, gout, and severe kidney disease. The patient has been evaluated by orthopedics, physical medicine, and pain management. The patient takes Norco pain medication three times a day for pain relief. The last Norco refill is dated 12/13/19 for 90 tablets. The patient requested a Norco refill on 1/7/20. The provider requested a urine drug test. The urine drug test was positive for tetrahydrocannabinol (THC, the active ingredient in marijuana), opiates (contained in the Norco) and hydrocodone (contained in the Norco).

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 gout, then check the rights and deadlines that apply to your plan.