Pulmonary Hypertension: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Uptravi. The submitted documentation supports the medical necessity of the requested medication. This patient has been diagnosed with WHO group 1 pulmonary hypertension. Uptravi is a prostacyclin receptor agonist which has been approved by the U.S. Food and Drug Administration for the treatment of patients with WHO group 1 pulmonary artery hypertension to delay disease progression and reduce the risk of hospitalization. The Health Plan has denied Uptravi and noted that the patient has not tried an endothelial receptor antagonist. The medical literature does not indicate that an endothelial receptor antagonist is indicated prior to pursuing treatment with Uptravi. There is sufficient support for the requested medication in this clinical setting.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Adcirca for treatment of her medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has primary pulmonary hypertension as the wedge pressure was normal and the pulmonary artery pressure was very high. The current medical evidence supports Adcirca in this clinical setting. Combination therapy with the addition of Adcirca is a standard of care in this patient’s case. All told, the requested medication Adcirca is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned.

Where the denial was upheld

The patient is a 60-year-old female with pulmonary hypertension. Her physician has stated her pulmonary pressures are elevated. She is taking multiple medications for management of her medical condition. In addition, her physician has recommended the addition of Viagra to the patient’s medication regimen for treatment of her pulmonary hypertension.The patient is a 60-year-old female with pulmonary hypertension. According to a hospital summary dated 7/15/04, the patient has multiple medical problems including pulmonary hypertension, systemic lupus erythematosus (SLE), congestive heart failure, hyperlipidemia, diabetes mellitus, and status post DVT/PE.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Synagis injections for treatment of the enrollee’s hypoplastic left heart syndrome, cerebral palsy, and pulmonary hypertension. Findings: The physician reviewer found that the use of Synagis in this patient is not medically necessary. The use of Synagis has remained under strict criteria so that its use maximizes patient benefit and efficacy while not being overused. The most widely accepted guidelines for the use of Synagis are published by the American Academy of Pediatrics (AAP) Committee on Infectious Diseases and Bronchiolitis Guidelines Committee, and were last updated in 2014. These guidelines indicate there is no established role for RSV prophylaxis after 24 months of age for any patient regardless of any risk factors.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for pulmonary hypertension was denied, the published record says the denial is worth fighting.