Birth Control denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Orilissa 200 mg tablets received monthly. The records document that this patient has a history of symptomatic uterine fibroids, with a primary presenting symptom of dysmenorrhea or severe pain with menses. As noted in the medical literature, several treatment options exist for the management of patients with symptomatic uterine fibroids. Treatment options should consider an individual patient’s symptoms, the severity of the symptoms and the patient’s desire for future childbearing.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Annovera birth control ring.Combined (estrogen-progestin) hormonal contraception is highly effective and available in multiple forms and formulations, including as a vaginal ring. In the United States, there are two commonly available combined hormonal contraceptive rings, the etonogestrel/ethinyl estradiol ring and the segesterone acetate/ethinyl estradiol ring. This second formulation is known commercially as Annovera. The hormonal contraceptive vaginal rings offer the same benefits as the other estrogen-progestin combined methods but do not require daily or weekly use. More specifically, Annovera is a one-year reusable segesterone acetate/ethinyl estradiol ring. The ring is worn for three weeks and removed for one week, and that pattern is repeated for a total of 13 cycles.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Yasmin for treatment of the enrollee, who reports a history of menstrual pain.Findings: The physician reviewer found that there is no documentation that this patient has failed a trial of generic oral contraceptive pills that are specifically of the same formulation as Yasmin. Failing other oral contraceptive pills or generics of other pill formulations is not comparable. There are many different formulations of oral contraceptive pills, each with a varying combination of estrogen and progestin. Specifically, Yasmin is drospirenone/ethinyl estradiol. In this case, the Health Plan has offered the patient several different alternatives to Yasmin which in and of themselves are appropriate equivalents.

Findings: The physician reviewer found that an enrollee has requested authorization and coverage for Lupin levonorgestrel and ethinyl estradiol tablets USP 0.1mg for birth control due to a diagnosis of Polycystic Ovarian Syndrome. There is a place for deference to branded birth control pills and the American College of Obstetrics and Gynecology has addressed this issue. The medical issue for why the patient is on the pill, management of her polycystic ovarian syndrome (PCOS), does not specifically command a particular formation of birth control pill. However, generic oral birth control pills (OCPs) approved by the FDA have been shown to be bioequivalent and pharmaceutically equivalent to the branded product and are interchangeable. There is no evidence-based data to challenge this conclusion.

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