Diagnosis: Blood Disorder.
Treatment: Pharmacy/Prescription Drugs (Pradaxa).

The insurer denied the Pradaxa. The denial is upheld in whole.

The patient is a male with a history of chronic deep vein thrombosis. The patient is stated to be refractory to Eliquis and Xarelto. The patient is on an acetaminophen-hydrocodone that is stated by the provider to interact with warfarin. Pradaxa has been recommended and is under review.

The health plan's determination is upheld.

The patient has failed the formulary drugs Eliquis and Xarelto, and, thus, they are not appropriate for this patient. The formulary drug warfarin has similar clinical efficacy to the non-formulary Pradaxa and is not contraindicated in this clinical scenario. A LexiDrugs interaction check states "...Acetaminophen may enhance the anticoagulant effect of Vitamin K Antagonists. This appears most likely with daily acetaminophen doses exceeding 1.3 or 2 grams per day (g/day) for multiple consecutive days.... Monitor for increased therapeutic effects of anticoagulants if acetaminophen is initiated/dose increased, or decreased effects, if acetaminophen is discontinued/dose decreased.... Use for more than 3 consecutive days may warrant additional international normalized ratio (INR) testing....".

Therefore, if this patient is intensively monitored, there is likely minimal risk to the use of warfarin with his current medical regimen.