Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for hydrocortisone acetate suppositories. Findings:  The physician reviewer found that the enrollee has hemorrhoids and at an office visit reported a two year history of intermittent blood in his stool that is minimal, occurs once a week and is pinkish in color. He refused a rectal exam. His provider prescribed Proctosol HC cream, and upon enrollee request, referred him to a gastroenterology (GI) specialist. On a follow-up visit, the enrollee indicated his hemorrhoids are getting better after using the cream, but also requested a suppository for his hemorrhoids. A prior authorization request was submitted for hydrocortisone acetate suppository on the basis that Proctosol-HC cream was not effective after one month of use, and based on the enrollees previous experience of the suppository being fast-acting and effective. There is no medical literature that supports the superiority of a rectal suppository over topical remedies for hemorrhoid management. According to the medical literature, non-invasive medical treatments, such as pills, suppositories, cream and wipes are intended more for acute symptom control (pruritus/itchiness, bleeding) than to cure the underlying hemorrhoids. While the literature supports oral preparations, such as flavonoids as a phlebotonic agent and is superior to topical remedies in symptom control, support for suppositories over topical remedies is lacking. Literature indicates the diagnosis of hemorrhoids should be determined by providers physical examinations rather than enrollee history in order to rule out other anorectal pathologies, such as anal fissure, fistula, pruritus, and anal cancer, and to assess the severity of the enrollees condition including grading of hemorrhoids. Review of the record provides insufficient evidence of the diagnosis of hemorrhoids established by performing a rectal exam. Proctosol-HC cream was prescribed solely based on enrollees report of having blood in stool and enrollee history of hemorrhoids. There is no evidence in the record of a gastroenterology visit, despite the request for referral. At a follow-up visit, the provider did not perform a rectal exam to evaluate the severity of the condition before submitting the pre-authorization request for the hydrocortisone acetate suppository. Inconsistent to the providers request, the medical note for the enrollees last office visit prior to the authorization request indicated the enrollee started getting better after using the cream. These records do not support the request for the suppository on the basis that Proctosol-HC cream is not effective. The literature does not support the suppository is the next-line of treatment when a topical remedy (i.e. Proctosol-HC cream) fails. Final Result: The reviewer determined that the requested treatment is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified gastroenterologist, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.