Diagnosis: End-stage renal disease
Treatment: Sevelamer Carbonate 2.4GM POW
The insurer denied the Sevelamer Carbonate 2.4GM POW.
The denial is upheld.

The patient is a female with end-stage renal disease. Sevelamer carbonate was
prescribed for hyperphosphatemia.

No, the treatment with Sevelamer Carbonate is not medically necessary.

There is no documentation that the patient has failed or has been intolerant to and has no contraindication to Velphoro for treatment of hyperphosphatemia (Velphoro is FDA [Food and Drug Administration]-approved for treatment of hyperphosphatemia in end-stage renal disease).

In summary, sevelamer carbonate is not medically necessary. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.