Vioxx denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 57-year-old male who has been diagnosed with osteoarthritis. In addition, the patient has a history of gastroesophageal reflux disease. The patient is unable to tolerate Alleve and ibuprofen. Further, trials of Relafen and Naprosyn were unsuccessful. The patient has requested authorization and coverage for Vioxx. The Health Plan has denied the patient’s request on the basis that Vioxx is not medically necessary for treatment of the patient’s osteoarthritis.The Health Plan’s denial should be overturned. The patient is under age 65 and carries a diagnosis of osteoarthritis. Alleve and ibuprofen caused the patient to experience gastrointestinal upset and cramping. Additionally, the patient has failed a trial of Relafen, a low-gastrointestinal risk NSAID. As such, the medical necessity of Vioxx has been established.

The mother of a six-year-old female enrollee requested authorization and coverage of the medication Vioxx for treatment of the enrollee’s medical condition. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollee’s chronic recurrent multifocal osteomyelitis (CRMO).One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plan’s denial on the basis that the requested medication is medically necessary.

Where the denial was upheld

The patient is a 52-year-old male with pleuritic chest pain who was prescribed Vioxx by his cardiologist and primary physician. The patient has a past history of gastroesophageal reflux disease (GERD), hypertension, and hypercholesterolemia. The patient has a history of pericarditis in 1980. Electron beam CT scan of the chest and coronary arteries showed normal lung tissue and pleura as well as a normal coronary calcium score. The patient’s cardiologist determined the patient’s chest pain was pleuritic and prescribed Vioxx. The Health Plan has denied authorization for Vioxx indicating that there is no documentation that the patient had tried alternative low risk NSAIDs.At issue is whether Vioxx is medically necessary for treatment of the patient’s pleuritic chest pain. Standard treatment for pleurisy is non-steroidal anti-inflammatory drugs (NSAIDs).

A 57-year-old female enrollee requested authorization and coverage of an increase in the quantity and dosage of her monthly Vioxx prescription for treatment of chronic myofascial pain. The Health Plan denied the enrollee’s request indicating that the requested increase in quantity and dosage of the prescription is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plan’s denial on the basis that the requested medication is not medically necessary.

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