Diagnosis: Type 1 diabetes mellitus

Treatment: Apidra

The insurer denied coverage for Apidra.

The denial is overturned.

This female patient has a history of type 1 diabetes mellitus.

The formulary drug options are likely to cause the claimant an adverse reaction. The patient has tried and failed NovoLog per the provider, and Fiasp is similar to NovoLog molecularly, therefore, the effects of Fiasp would be expected to work in the manner NovoLog did.

Fiasp has not been tried, however, as it has similar molecular structure as NovoLog, it would be expected that the patient would respond to Fiasp as she did with NovoLog-which was uncontrolled glucose levels. So, Fiasp would not be reasonable to trial in this claimant.

The patient has responded well to Apidra. She has tried and failed NovoLog. In addition, this request is for continuity of care with a drug for a patient who has responded well, without adverse events and is successfully controlled.

Based on the medical facts from the available records, claim documentation, and any additional information obtained from the treating provider(s) from the Endocrinology, Diabetes, & Metabolism/Internal Medicine, the requested drug is likely to produce a more clinically beneficial outcome.

The current medical literature supports coverage of the requested drug as an alternative if the patient has tried and failed Fiasp or NovoLog.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The carrier's denial of coverage for Apidra is overturned. The medical necessity is substantiated.