Vitamins denials: what the review data shows

Where the denial was overturned

The parent/conservator of a 26-year-old male enrollee has requested for titration and individual cognitive therapy for treatment of the enrollee’s schizophrenia. Findings: The physician reviewer found that antipsychotic medication has been the standard of care for those afflicted with a formal thought disorder, such as schizophrenia, since the 1950s (Kreyenbuhl, et al.). A recent paper by Lieberman noted that, “We currently have 20 marketed antipsychotic drugs available for use, which form the cornerstone of our treatment for schizophrenia.” In this particular case, the use of Risperdal is consistent with the standards of good medical care in the United States.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Venofer 200 mg weekly for five cycles. On review of the available records, this patient is pregnant and she presents with a history of iron deficiency anemia. The provider noted that the patient has been unable to tolerate treatment with oral iron due to chest pain. The patient’s provider has recommended treatment with Venofer. Non-physiologic anemia in pregnancy can have serious adverse consequences for the mother and child (Juul, et al.). This patient’s laboratory results included a hemoglobin below 11 and ferritin below 15, which suggest iron deficiency anemia. The patient has classic iron deficiency anemia during this pregnancy in addition to a history of iron deficiency anemia with poor tolerance for oral iron.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient who was diagnosed with attention deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), and depersonalization-derealization syndrome and was prescribed Enlyte supplementation. Findings: The physician reviewer found that patient subsequently reported that she felt a bit better, and it was noted that she has also had some good things happen. The provider noted improvement of mood and ADHD was noted but “there is room for more”. Subsequently, the patient reported that she had stopped taking certain medications. She was advised to restart Enlyte and to return in April 2023. The Health Plan has denied this request indicating that the requested treatment was not and is not medically necessary.

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with dysphagia. The patient has a past medical history of hypertension, asthma and prostate cancer. An emergency department report noted the patient had complaints of nausea, vomiting with hematemesis, dizziness, bloody stool, and diffuse abdominal pain. The patient declined esophagogastroduodenoscopy (EGD) and colonoscopy studies. An authorization request noted that the patient endorsed difficulty swallowing in the past. Per the records, the patient has been receiving Ensure. A review of the record indicates that the patient has been diagnosed with dysphagia but there is no detailed description or investigation of dysphagia. There is no active plan documented in any report addressing dysphagia as an active ongoing problem. The patient has requested coverage for Ensure.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Vitaminswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.