Anti-hypertensives denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with hypertension, dyslipidemia, and atherosclerotic heart disease. The records noted a history of percutaneous coronary intervention. The patient was noted to have experienced left-sided chest tightness associated with weakness and shortness of breath in 2006. The patient subsequently underwent cardiac stent placement. The patient was noted to have undergone a second cardiac stenting procedure. A myocardial perfusion study revealed normal left ventricular perfusion. The patient’s blood pressure was noted to be 146/90. The provider discontinued Azor and prescribed Edarbyclor and amlodipine. The patient denied chest pain, shortness of breath, and palpitations. The patient’s blood pressure was noted to be 140/100. Samples of Edarbyclor were provided to the patient.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Bystolic 5 mg daily. While beta blockers are not regarded as the optimal first-line therapy for the management of hypertension, they may be indicated in certain clinical situation, especially in conjunction with an angiotensin II receptor blocker (ARB) as in this case, including for patients with rhythm disturbances, angina and prior myocardial infarction. In this case, the patient has a history of frequent premature ventricular contractions (PVC). Medical literature notes that potential PVC triggers include uncontrolled hypertension, and that the most common treatment medical therapy for patients with significant or persistent PVC related symptoms includes beta blockers.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Pushtronex 420 mL once a month. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of hyperlipidemia.The submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the records provided the patient has a history of hyperlipidemia on maximum tolerated statin medication and increased coronary risk but no documented cardiovascular disease. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Praluent for treatment of the enrollee’s familial hyperlipidemia, coronary artery disease, and ischemic chest pain. Findings: The physician reviewer found that based on the records provided, the patient presents with hyperlipidemia and intermittent chest discomfort but no provokable ischemia on stress testing and no obstructive coronary disease on angiography. Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease as evidenced by myocardial infarction, coronary bypass, provokable ischemia on stress testing, stroke, or transient ischemic attack who require additional lowering of LDL cholesterol. This patient does not meet these criteria.

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 Anti-hypertensives, then check the rights and deadlines that apply to your plan.