Diagnosis: Mixed hyperlipidemia
Treatment: Vascepa (icosapent ethyl)
The insurer denied the Vascepa (icosapent ethyl).
The denial is upheld.

The patient is a male. He has history of CAD (coronary artery disease) and diabetes. It was stated that he is on maximum dose statin, and his TG (triglyceride) is greater than 600. He had documented TG (triglyceride) of 659. LDL (low-density lipoprotein) could not be determined due to high levels of TG (triglycerides). There is no documentation of failure or intolerance to Zetia. The request is to continue Vascepa.

No, unless patient tries and fails Zetia, the treatment with Vascepa is not medically necessary.

Community practice suggests that high-dose statin (which the patient is on), and Zetia (which he is not prescribed) be tried and failed prior to use of Vascepa. There is no documentation that the patient has tried and failed Zetia. There is not documentation that the patient has any contraindications to Zetia.

Therefore, given the above, the treatment with Vascepa is not medically necessary for this patient at this time.

The decision is consistent with guidelines and best practice.