Crestor 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: A patient has requested authorization and coverage for brand-name Crestor 40 mg.The records provided for review document that this patient has established coronary artery disease, which is an indication for secondary prevention with high-intensity statin therapy. This recommendation aligns with the guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA). The provider noted that the patient experienced urticaria with rosuvastatin, but the patient was able to tolerate treatment with brand-name Crestor. This suggests excipient intolerance rather than class intolerance due to a non-active ingredient hypersensitivity.

A 39-year-old male enrollee has requested for Crestor for treatment of his hyperlipidemia. Findings: The physician reviewer found that a lipid-lowering agent should be discontinued if there is significant intolerability, either in the form of patient side effects or abnormal laboratory data. Therefore, it is medically appropriate for the patient to continue on Crestor. The use of this lipid-lowering medication is supported by the American College of Cardiology (ACC) guidelines for patients with dysplipidemia.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Crestor 5 mg once a day, Relpax 40 mg once a day, Diovan HCTZ 80-12.5 mg once a day, and Klonopin 0.5 mg once a day. In this case, the patient has medical problems including hyperlipidemia, hypertension, migraine headaches and chronic twitching of the eyelid. The medications including Crestor (rosuvastatin), Diovan HCTZ (valsartan/hydrochlorothiazide), Relpax (eletriptan) and Klonopin (clonazepam) are medically appropriate treatment for her medical conditions. However, the records provided for review do not support the medical necessity of the brand name formulations of these medications. Specifically, the documentation does not report that the patient has experienced any adverse reactions to the generic equivalents of these medications. When the U.S.

Nature of Statutory Criteria/ Case Summary: The enrollee requested coverage for the medications Crestor 10 mg tablets and Cozaar 50 mg tablets. Review of the records reveals only one blood pressure reading that was elevated on 2/10/17 as 160/80. There is no laboratory lipid data that would confirm whether the patient was or was not responding to the medication he was taking. There is also no evidence of a side effect that could be attributed the lipid lowering medications being taken, such as muscle aches. There is no information provided concerning response to the brand name medications requested compared to the generic equivalent. There is also no information in the records of adverse drug effects to a generic version of both of these medications.

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