High Cholesterol denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) of the heart. Findings: The physician reviewer found that records provided for review support that this patient has a borderline 10-year arteriosclerosis cardiovascular disease risk. Based on current published guidelines, moderate intensity statin therapy may be considered for this level of low density lipoprotein (LDL) cholesterol with a borderline risk profile. The CT of the heart was indicated to assess the patient’s coronary calcium score, which is a risk-enhancing factor that would reclassify the patient to a higher risk score and support treatment with cholesterol lowering statin therapy. Given the patient’s coronary calcification score of zero was helpful to determine whether the patient required long-term treatment with statin therapy.

A 64-year-old male enrollee has requested Zetia 10mg for the treatment of his high cholesterol. Findings: The physician reviewer found that the patient has been taking Crestor at the maximum dose. This dose of Crestor is stronger than or equivalent to Lipitor 80mg or simvastatin 80mg per day (formulary alternatives). There is no medical advantage to requiring that the patient switch to the maximum dose of the formulary statin to prove that he will not achieve his target. In this case, Zetia is medically appropriate for treatment of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a follow-up lipoprotein(a) test. Guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations, including the American College of Cardiology (ACC) and the American Heart Association (AHA). These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2 (Lp-PLA2), subclassifications of low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), lipoprotein(b), C-reactive protein, high-sensitivity C-reactive protein (CRP), insulin, insulin resistance, fibrinogen, genetic testing, and homocysteine.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. There is a lack of clinical studies in current medical literature demonstrating that strategies to correct the residual risk potentially identified by novel lipoprotein testing, such as the service at issue, will further reduce cardiac risk. It remains unclear if that such testing adds significant actionable information to what is already known from a fasting lipid panel.

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