Diagnosis: Left thoracotomy and Lung Resection

Treatment: Dronabinol 2.5mg OR CAPS

The insurer denied Dronabinol 2.5mg OR CAPS. The denial was upheld.

This is a male patient with a history of colorectal cancer, status post left thoracotomy and left upper lingular wedge resection with left lower pneumonectomy and metastasectomy. In mid-2019 the patient was seen for a follow-up evaluation. His physical exam indicated his wounds were healing well. He did have some complaints of continued weight loss and did appear much thinner. His vital signs revealed he was 5 foot 10 inches tall weighing 163 pounds. It was recommended that the patient utilize Marinol for appetite stimulation for two weeks and then follow-up. Further documentation from late 2019 included a discussion with patient that indicated he felt "a little better today" and reported a 10-pound weight gain since starting Marinol 2 weeks prior.

According to the current medical literature, Dronabinol is U.S. Food and Drug Administration (FDA)-approved for the treatment of anorexia associated with weight loss in patients with autoimmune deficiency syndrome (AIDS) and for nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments. Within the submitted documentation, it does detail that this patient has a diagnosis of cancer and has had previous chemotherapy treatment. However, it does not appear that the medication is appropriate as there is a lack of documentation supporting that the patient continues with chemotherapy. The medication is not approved to treat loss of appetite. The submitted case notes do detail that there are other medications from the patient's preferred drug list for loss of appetite. Therefore, as there is a lack of current peer-reviewed literature detailing this medication has greater benefit than the patient's preferred drugs.

Based on the above, the medical necessity for Dronabinol 2.5mg OR CAPS is not substantiated. The insurer's denial is upheld.