Migraine preventive therapy
Fictional criteria
- Patient is at least 18 years old.
- At least 8 migraine days per month are documented.
- Failure, intolerance, or contraindication to 2 preventive medication classes.
- Quantity does not exceed 1 injection every 30 days.
Case
A 38-year-old has 12 migraine days per month. Topiramate was used for 3 months and stopped because of cognitive adverse effects. Propranolol appears on the medication history, but no dose, duration, outcome, or contraindication is documented. The request is for 1 injection every 30 days.
Quantity exceeds the policy limit
Fictional criteria
- Diagnosis of acute migraine is documented.
- Failure of 2 preferred triptans.
- Maximum quantity is 10 tablets per 30 days.
Case
A 45-year-old has documented inadequate response to sumatriptan and rizatriptan. The requested drug is otherwise appropriate. The prescriber requests 16 tablets per 30 days and provides no rationale for the higher quantity.
Step-therapy bypass
Fictional criteria
- Diagnosis of chronic idiopathic constipation.
- Trial of the preferred agent for at least 30 days, unless contraindicated.
- Requested dose is within the policy limit.
Case
A 67-year-old has chronic idiopathic constipation. The preferred drug was not tried. The chart documents a previous bowel obstruction, and the fictional policy lists bowel obstruction as a contraindication to the preferred therapy. The requested dose is within limits.
Continuation without a measurable response
Fictional criteria
- For continuation, the record must show at least a 50% reduction in monthly symptom days from baseline.
- The current dose must be within the policy limit.
Case
Baseline was 16 symptom days per month. The continuation note states that the patient is 'doing much better' and tolerating treatment. No current symptom frequency is recorded. Dose is within limits.
Pediatric weight-based dose
Fictional criteria
- Diagnosis is eosinophilic esophagitis.
- Age is at least 1 year.
- For body weight 15 to less than 30 kg, the covered dose is 200 mg every 2 weeks.
- For body weight 30 to less than 40 kg, the covered dose is 300 mg every 2 weeks.
Case
An 11-year-old weighs 26.7 kg. The prescriber requests 300 mg every 2 weeks.
New start submitted as continuation
Fictional criteria
- Continuation requests require paid-claim history or documentation of ongoing use during the previous 120 days.
- Continuation also requires a positive clinical response.
- New-start requests require 2 previous treatment trials.
Case
The request is marked continuation. There is no paid-claim history or documentation of current use. The note says the prescriber 'plans to start' the medication. One previous treatment trial is documented.
Conflicting diagnosis
Fictional criteria
- The medication is covered for plaque psoriasis.
- The medication is not covered for cosmetic hair loss.
- Diagnosis must be supported by the most recent specialist note.
Case
The electronic request lists plaque psoriasis. The most recent dermatology note discusses only cosmetic hair loss and does not mention psoriasis. An older problem list includes psoriasis.
Duplicate therapy
Fictional criteria
- The requested therapy is covered for type 2 diabetes when criteria are met.
- Concurrent use with another drug from the same therapeutic class is not covered.
Case
The diabetes criteria are met. Pharmacy claims show an active 84-day supply of another medication in the same therapeutic class dispensed 2 weeks ago. The note does not state that the previous drug will be stopped.
Appeal with new information
Fictional criteria
- The original request was denied for no documented preferred-drug trial.
- On appeal, new clinical information may be considered.
- The preferred drug may be bypassed for a documented serious hypersensitivity reaction.
Case
The appeal includes an emergency-department note documenting angioedema after the preferred drug. The requested medication otherwise meets all criteria.
Time pressure and incomplete data
Fictional criteria
- Urgent requests must be completed within the employer's expedited turnaround time.
- A decision cannot be based on an unreadable laboratory report.
- Clinical ambiguity may be escalated according to procedure.
Case
An urgent request is near its deadline. The only laboratory report is unreadable, and the value is required for coverage. A technician suggests approving because the prescriber is likely to resend it later.