Nexium denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nexium and Benicar. Findings: The physician reviewer found that the request for Nexium and Benicar has been established as medically necessary for treatment of the patient’s medical condition. Based on the records provided for review, the patient has increased cardiovascular risk, cerebrovascular disease and both hypertension and acid reflux that have been managed long-term with Benicar HCT and Nexium. In this circumstance, continued use of these medications as the patient transitions to a new primary care provider is reasonable and appropriate. Since a temporary lapse in these medication may be severely detrimental to the patient’s health continued coverage of her medications is medically necessary for treatment of the patient’s medical condition.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has a history of esophagitis and gastroesophageal reflux disease (GERD). The patient has requested authorization and coverage for Nexium (40mg once daily). In this case, the record reveals that the patient has been diagnosed with grade 3 esophagitis and reflux esophagitis with erosive reflux changes in the squamocolumnar mucosa. The patient has failed omeprazole and has tolerated Nexium capsules despite dysphagia and pill aversion due to Nexium’s small size. All told, the medication Nexium (40mg once daily) is medically necessary for the treatment of the patient.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient’s medical condition.

Where the denial was upheld

A 54-year-old female enrollee has requested for Nexium and Lipitor for treatment of her hypercholesterolemia and gastroesophageal reflux disease. Findings: The physician reviewer found that proton pumps inhibitors (PPIs) continue to be the backbone of therapy for acid suppression and continue to be the standard of therapy for the treatment of GERD. All PPIs decrease acid secretion by inhibiting parietal cell proton pumps. From chemical and pharmacodynamics points of view, subtle differences that exist among the PPIs may influence clinical activity. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. It is medically appropriate to require that the patient have a trial of formulary alternatives such as Omeprazole, Aciphex, or nonformulary alternative, Prevacid.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Nexium for treatment of her gastroesophageal reflux disease. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as to manage symptomatic gastroesophageal reflux disease and acid hypersecretory states. Duration of action, side effects, and cost characterize proton pump inhibitor variations. No particular proton pump inhibitor can claim overall superiority, such that as a class proton pump inhibitors are interchangeable. In this patient’s case, the available records do not support that her gastroesophageal reflux disease is advanced, nor has she demonstrated intolerance to specific proton pump inhibitors.

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