Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Subacute and Chronic Vaginitis
Treatment: Flucytosine Compound
The insurer denied: Flucytosine Compound
The denial is overturned.

The patient is an adult female with chronic pelvic pain, painful intercourse, migraines with aura, and recurrent vaginitis. She has yeast infections post menses. She gets irritated by pads/tampons. She has been on progesterone only pills but still has heavy menses. She has tried estrogen, Monistat, and boric acid without improvement. She had a culture and grew out candida glabrata. The plan is for Flucytosine compound.
The request was denied as the formulary options have not been tried and failed. This is being appealed.

The health plan should cover the proposed treatment.

Candida glabrata is a frequent vaginal colonizer that has low vaginal virulence and rarely causes symptoms, even when identified by culture. Therefore, we make every effort to exclude other causes of symptoms and only treat candida glabrata vaginitis when all other potential sources of the vaginal symptoms have been addressed. When treatment is elected, candida glabrata does not respond to typical first-line therapies because of inherent resistance or low-level drug susceptibility. 
Candida glabrata has emerged as the second-most-common agent of candidiasis, trailing only candida albicans. Its emergence parallels the introduction and wide-spread clinical use of triazoles, such as fluconazole. In contrast to candida albicans, which typically exhibits a good response to fluconazole, candida glabrata exhibits intrinsically low fluconazole susceptibility. 
Furthermore, under selective pressure, candida glabrata readily mutates to fluconazole resistance. Although studies specific to treatment of candida glabrata are limited, treatment with vaginal boric acid or vaginal nystatin are the first line recommendations as these drugs are reasonably available, generally well tolerated, and have some supporting evidence. Vaginal boric acid 600 milligram (mg) capsule nightly for two to three weeks resolves symptoms in roughly 70 percent of patients with confirmed candida glabrata. The other preferred option is Nystatin suppository 100,000 units in vagina at night for 14 to 30 nights (duration varies with disease severity). Patients with vaginitis due to highly azole resistant Candida glabrata can be particularly difficult to treat. One option for treatment includes Flucytosine (1 gram) and amphotericin B (100 milligrams) formulated in lubricating jelly base in a total 8 grams delivered dose, used per vagina once daily for 14 days. This has demonstrated significant improvement, both clinically and microbiologically. In review of the information provided, the patient has had recurrent vaginitis for 7 months that has not responded to traditional treatments including miconazole, fluconazole, and boric acid. The culture grew out candida glabrata, which has a high resistance to the formulary option of fluconazole, making the formulary option ineffective for this patient. Also, the metronidazole and tinidazole are not options for yeast treatment. Therefore, the requested medication is more likely to be effective versus the formulary options. Without this the patient will continue to have recurrent vaginitis.