Celebrex denials in California external review

What the reviewers wrote

Where the denial was overturned

This patient is a 72-year-old male who requires symptom control for osteoarthritis and spinal stenosis. He had aortic valve replacement 12 years ago, and as a result will require life-long anticoagulation with Coumadin. The patient was hospitalized nine years ago for a severe hemarthrosis of the left knee accompanied by a severe hematoma of the left thigh. His physician notes that a trial of acetaminophen failed to control his arthritis-related symptoms, and for the past five years that patient has used Celebrex successfully without further bleeding episodes or difficulty managing his anticoagulation. The Health Plan has denied the patient’s request for continued authorization of Celebrex citing a lack of medical necessity.I find that the use of Celebrex is medically appropriate for this patient.

Nature of Statutory Criteria/ Case Summary: This is patient with diagnoses of gastritis, osteopenia, and chronic bilateral hip and back pain from degenerative disc disease.The patient’s primary care physician (PCP) noted she was having trouble sleeping and having to limit her activity due to her chronic pain in the hips, back and other joints. Celebrex 200 mg capsules were recommended as other non-steroidal anti-inflammatories are contraindicated due to her history of gastritis confirmed by endoscopy in 2018. Another provider reported that ibuprofen taken over the prior two months was not effective for her chronic pain and recommended Celebrex. At issue is whether the requested medication, Celebrex (celecoxib) 200 mg is medically necessary to treat the patient’s medical condition.

Where the denial was upheld

Physician 1The patient is a 74-year-old man who was initially diagnosed with colon cancer in 1999. His initial treatment is unknown. He has recently been found to have three very small lung nodules, which have not been biopsied. The patient’s oncologist believes they represent metastases to the lung, but feels that there is no advantage to instituting chemotherapy at this point in time. He has recommended the use of high dose Celebrex in an effort to control the metastases. The Health Plan has denied authorization for Celebrex indicating that its use is considered investigational for treatment of the patient’s medical condition.Celebrex is a COX-2 inhibitor, which has found wide use in many rheumatologic conditions. It also purportedly has anti-angiogenic properties; therefore, there is interest in its potential usefulness in cancer.

The patient is a 63-year-old female with a history of degenerative disc disease as well as degenerative arthritis of the lumbar spine. She underwent discectomies at L4-5 and L5-S1. Following surgery, the patient has apparently had persistent or recurrent symptoms with lumbar pain and radiating pain to both legs. Treatment with ibuprofen provided no relief at 600mg and Celebrex 200mg was started in November 2003. This was said to provide greater benefit, with improvement in radiating pain but persistence of right buttock pain. The submitted information indicates that the patient is sensitive to medications but this is not documented in the provided clinical records. Nor do the submitted records note prior use of NSAIDs other than ibuprofen. The patient has requested authorization for Celebrex.

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