Aciphex denials in California external review

What the reviewers wrote

Where the denial was overturned

A 65-year-old male has requested Aciphex for treatment of his gastroesophageal reflux disease (GERD). Findings: The physician reviewer found that the patient has tried and failed several different proton pump inhibitor (PPI) medications, which are on the Health Plan’s list of preferred PPIs. Many patients respond better to one PPI than any others, as in this patient’s case. The patient’s cardiac conditions have been investigated, as well. Therefore, it appears that this patient has attempted to manage his heartburn with other conservative treatment modalities, prior to trying Aciphex. As this patient has not found relief of his symptoms with other PPIs and a trial of Aciphex has been beneficial in the treatment of his symptoms, it is appropriate that the patient be treated with Aciphex.

A 51-year-old female enrollee has requested Aciphex for treatment of her chronic gastritis. Findings: The physician reviewer found that Nexium is the S-isomer of omeprazole. Based on the records provided, the patient developed an allergic reaction to Nexium. Not only is omeprazole not indicated for this patient, she should avoid any related compounds. Omeprazole is a related compound to Nexium, and is in fact very similar. Therefore, it is contraindicated to give omeprazole to this patient since a rechallenge may cause a very severe reaction with potentially life-threatening consequences. The patient has been taking Aciphex with benefit and without untoward side effects. It is medically appropriate for the patient to remain on Aciphex and avoid taking omeprezole, Nexium and Prevacid.

Where the denial was upheld

A 34-year-old female enrollee has requested the medication Aciphex for the treatment of her chronic dyspepsia. Findings: The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) and dyspepsia continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms of dyspepsia and healing of erosive as well as nonerosive esophagitis. PPIs continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours, and act by covalently binding to cysteine residue in H, K-ATPase (the proton pumps) in the membrane of the secretory canaliculi of parietal cells. Differences in the molecular structures of specific PPIs result in different cysteine residues targeted.

A 62-year-old female enrollee has requested Aciphex for the treatment of her condition. Findings: The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been seen with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19.

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