Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid arthritis

Treatment: Orencia

The insurer denied coverage for Orencia

The denial is overturned
 

The patient is an adult female seeking coverage for Orencia 750 milligrams (mg) intravenous at weeks 0, 2, and 4 and then every 4 weeks for the treatment of rheumatoid arthritis.

The patient was seen for a follow-up visit related to rheumatoid arthritis.  The patient had a recent flare of symptoms.  It was questionable if this was related to the patient having to take Enbrel every other week.  The patient had seropositive rheumatoid arthritis that was diagnosed many years ago.  The patient had been on Enbrel and methotrexate.  The patient started Enbrel many years ago,  The patient had been having trochanteric bursitis pain and occasional hand stiffness.  The patient developed lymphoma about eight years ago, which is in remission.  The patient's Vectra score was 50 which was up from 22.  The review of systems was positive for morning stiffness.  The physical exam findings noted synovitis of the wrists/ankles and swelling of the right first and second proximal interphalangeal joints.  The patient was assessed with rheumatoid arthritis with rheumatoid factor of the right wrist without organ or systems involvement.  There was a plan for Rituxan intravenous.

A request for Orencia was denied.  The request was denied as the documentation did not identify that the patient had poor response to medications on the preferred drug list.  It was recommended that the doctor consider utilizing Kevzara.  

The provider requested reconsideration for the patient's Orencia.  The patient was being treated for rheumatoid arthritis.  The patient was previously on Rituxan intravenous and went into remission.  The patient recently presented with joint pain, swelling, fatigue, and morning stiffness.  Repeat Vectra score was 50 with the last reading being 20.  The patient was at increased risk for radiographic progression since their rheumatoid arthritis was flaring.  The patient was afraid to use other agents.  The provider felt that Orencia intravenous may be helpful.  The patient had tried and failed Enbrel.  The patient could not take Xeljanz or Kevzara since they were in remission from lymphoma.

The Food and Drug Administration states that Orencia is indicated for the treatment of patients with moderate to severe active rheumatoid arthritis.  In this case, the patient had a flare of rheumatoid arthritis.  Prior treatments included prednisone, Enbrel, and Rituxan.  The patient could not take Xeljanz or Kevzara since they were in remission from lymphoma.  In this case, Orencia is supported by the clinical documentation.  The reported formulary alternatives are not the most appropriate treatment for the patient given a history of lymphoma.  There is increased risk to the patient with the formulary alternatives versus the current request.  The Food and Drug Administration recommends Orencia for the patient's clinical presentation and diagnosis.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Orencia for the treatment of Rheumatoid Arthritis is substantiated.