Stage IIC Ovarian Cancer: A Case Study
A review of the records reveals the member to be an adult female with a birth date of 01/30/1965. The member has a diagnosis of Stage IIC Ovarian Cancer Post-chemo nausea and vomiting. The member’s treating provider, Nicholas C. Lambrou, MD prescribed Sancuso transdermal patches for this member.
The carrier has denied coverage for the prescription Sancuso transdermal patches as not medically necessary. There is a letter from the carrier to the member dated 05/27/2016 which states in part:
“The specific reason for this denial of your appeal for Sancuso is that coverage guidelines had not been met based on AvMed’s Medical Department Procedure 07.035, ‘Processing Prior Authorizations - PA & Step Therapy Guidelines’and the manufacturers prescribing …show more content…
This was followed by Carboplatin and dose dense Taxol, which is a highly emetic treatment. She has been treated with Sancuso (granisetron) patches successfully to treat nausea and vomiting. This was denied by the Plan as not medically necessary because they require that a patient try and fail Zofran and Kytril (ganisetron) before Sancuso is used. In the appeal, her doctor only stated she failed oral antiemetics, but did not specify that Zofran and Kytril were tried.
Sancuso is an effective anti-emetic and is FDA-approved for the prevention of nausea and vomiting in patients receiving moderately and/or highly emetogenic chemotherapy for up to 5 consecutive days1,2. However, the member’s Plan specifically states that she must try and fail Zofran and Kytril (ganisetron) before Sancuso is authorized as medically necessary. Her treating physician’s appeal did not state this was done.
Therefore, the carrier’s decision in denying coverage for the requested prescription Sancuso transdermal patches was appropriate.
The requested prescription Sancuso transdermal patches are not medically necessary for the treatment of this member’s condition.
The previous denial should be
The carrier has denied coverage for the prescription Sancuso transdermal patches as not medically necessary. There is a letter from the carrier to the member dated 05/27/2016 which states in part:
“The specific reason for this denial of your appeal for Sancuso is that coverage guidelines had not been met based on AvMed’s Medical Department Procedure 07.035, ‘Processing Prior Authorizations - PA & Step Therapy Guidelines’and the manufacturers prescribing …show more content…
This was followed by Carboplatin and dose dense Taxol, which is a highly emetic treatment. She has been treated with Sancuso (granisetron) patches successfully to treat nausea and vomiting. This was denied by the Plan as not medically necessary because they require that a patient try and fail Zofran and Kytril (ganisetron) before Sancuso is used. In the appeal, her doctor only stated she failed oral antiemetics, but did not specify that Zofran and Kytril were tried.
Sancuso is an effective anti-emetic and is FDA-approved for the prevention of nausea and vomiting in patients receiving moderately and/or highly emetogenic chemotherapy for up to 5 consecutive days1,2. However, the member’s Plan specifically states that she must try and fail Zofran and Kytril (ganisetron) before Sancuso is authorized as medically necessary. Her treating physician’s appeal did not state this was done.
Therefore, the carrier’s decision in denying coverage for the requested prescription Sancuso transdermal patches was appropriate.
The requested prescription Sancuso transdermal patches are not medically necessary for the treatment of this member’s condition.
The previous denial should be