Diagnosis: Hyperlipidemia
Treatment: Vascepa
The insurer denied Vascepa.
The determination is upheld.

The patient has a diagnosis of hyperlipidemia. He was started on a high intensity statin with rosuvastatin 20 milligrams (mg). He presented for outpatient evaluation. His low density lipoprotein (LDL) was noted to be improved, but he had significant hypertriglyceridemia. Vascepa was added and is under review for medical necessity.

In this case, the patient is under 45 years of age and does not have established atherosclerotic cardiovascular disease, based on the information provided.

Vascepa is not medically necessary in this case. The patient does not have established atherosclerotic cardiovascular disease or high risk factors that would indicate the need for this medication. He does not have diabetes. Per the American Heart Association (AHA) guidelines for the treatment of blood cholesterol, Vascepa is not a recommended treatment for hypertriglyceridemia based on these guidelines (2). Therefore, it is not medically necessary.