
201908-120353
2019
United Healthcare Plan of New York
HMO
Gynecological
Pharmacy/ Prescription Drugs
Medical necessity
Upheld
Case Summary
The patient is a gravida (G) 0 female who is under care for dysmenorrhea. She was prescribed Lo Loestrin for oral contraceptive care by her gynecology provider. The patient reported that she has tried alternative therapies for contraceptive care and dysmenorrhea but has fallen ill for extended periods with these medications. The patient is noted to have no significant medical history. Her weight is 122 lbs. with a body mass index (BMI) of 19 kilograms per square meter (kg/m2). She was provided samples of Lo Loestrin Fe at her last visit. She had a normal exam. The subject under review is the medical necessity for Lo Loestrin oral contraceptive for the indication of dysmenorrhea.
Based upon a review of the medical records, correspondence from the patient and plan, and consideration of the peer reviewed medical literature, there is no medical necessity for Lo Loestrin for this patient. In this case, the patient is noted to have dysmenorrhea. This is effectively treated with oral contraceptive pills in most cases.
The patient has to try at least three plan-preferred medications and fail these prior to a finding of medical necessity is affirmed for a non-preferred agent (in this case Lo Loestrin oral contraceptives). The preferred agents include the following: Alesse-28, Aviane, Apri, Balziva, Cryselle, Estrostep Fe, Junel (FE), Portia, Reclipsen, Lo/Ovral, Ortho-Cept, Loestrin (FE) 1.5/30, Loestrin (FE) 1/20, Nordette, Ortho-Novum 1/35, Ortho-Novum 7/7/7, Ortho-Cyclen, Ortho-Tri-Cyclen, Ovcon 50, Trivora, Zenchent, Zovia 1/35, Zovia 1/50, generic Seasonale, Ortho Evra, and Nuvaring. There is no documentation that the patient has tried and failed any of these. Thus, there has been no failure of the preferred formulary alternatives in this case. There is no medical evidence that Lo Loestrin is superior in management of contraceptive care or dysmenorrhea. Thus, this agent would not be considered superior in the management of these health conditions. The requested Lo Loestrin would not be medically necessary for this patient.