Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Pharmacy/Prescription Drugs.

The insurer denied Prolia.
The health plan's determination is upheld.

The patient is a female with diabetes, hypertension, peripheral arterial disease and end-stage renal disease status post renal transplant x3. She has a history of chronic kidney disease with a creatinine of 1.5. A recent bone density study demonstrated a T score of -1.7 in the femur and 0.3 in the spine. The provider stated that the patient cannot take Fosamax. Prolia was prescribed for osteopenia. The subject under review is the medical necessity for Prolia.

The health plan's determination is upheld.

The use of Prolia is not medically necessary for this patient. The standard of care for treatment of osteopenia, including in patients with renal transplants, does not include Prolia. The patient has not failed or been intolerant to bisphosphonates and vitamin D or vitamin D analogs for the treatment of osteopenia. Bisphosphonates are not contraindicated in patients with renal transplants. In addition, the patient does not have a history of a fragility fracture and does not have osteoporosis as there is no T score of -2.5 or lower. Prolia is not approved for the treatment of osteopenia. In summary, Prolia is not medically necessary in this case based on the standard of care for treatment of osteopenia.