Diagnosis: Osteoporosis.
Treatment: Reclast intravenous (IV) Infusion.
The insurer denied the Reclast intravenous (IV) Infusion.
The denial is overturned.

The patient is a male with osteoporosis. The request for Reclast is under review. The prior request was denied as approval requires that the patient has severe intolerance, ineffective response, or contraindication to oral bisphosphonate therapy or the patient has had a prior fragility fracture or is especially high fracture risk. The attending physician is appealing this determination because this patient has a T-score of -2.9. He fractured his left tibia while roller skating. He stated it was not a big fall. He completed a two-year course of Forteo. He tried Fosamax three years ago, and again three months ago, and experienced severe gastrointestinal upset. He also tried and was intolerant to Actonel, which resulted in emergency room visit due to severe gastrointestinal upset.

Yes, the requested Reclast is medically necessary.
This patient has osteoporosis and has completed a two year course of Forteo. He has tried and had severe intolerance to both Fosamax and Actonel. Without Reclast, this patient is at risk of losing bone density that he gained with the Forteo treatment he received, which would put him at high risk for a fragility fracture. Therefore, yes, the requested Reclast is medically necessary.

This patient had a severe intolerance to oral bisphosphonates. The requested Reclast is medically necessary.