Diagnosis: Hyperlipidemia.
Treatment: Repatha SureClick 140 milligrams per milliliter.

The insurer denied the Repatha SureClick 140 milligrams per milliliter.
The denial is overturned.

The patient is a female with history of hyperlipidemia. There is documented intolerance to multiple statins and Zetia as well as full work up to confirm intolerance of these medications.

Yes, the proposed Repatha is medically necessary.

Per guidelines, indication for a PCSK9 (Proprotein convertase subtilisin/kexin type 9 serine protease) inhibitor would be intolerance or failure of statins and Zetia to reach goal in patients with hyperlipidemia. This patient meets these criteria and use is consistent with community practice.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

Treatment of hyperlipidemia as requested is appropriate care.