Diagnosis: Hyperlipidemia, unspecified
Treatment: Formulary exception for Livalo 2mg TAB, Pre-service
The insurer denied the Formulary exception for Livalo 2mg TAB, Pre-service
The denial is overturned

The patient is a female with solitary kidney and hyperlipidemia. The physician note states that she has tried and failed Pravachol, Zocor, Mevacor, Lipitor and Crestor, all due to myalgia. She has been on Livalo for many years. It was stated that she has tried and failed all formulary drugs. The request for continued use of Livalo was denied by the health plan due to lack of documentation of failed use of statins.

Yes, the health plan should cover the Formulary exception for Livalo.
Formulary exception allowed if the patient has documented intolerance to all statins. Initial review did not include that evidence. The follow-up appeal letter from the treating physician did document that history of trial and failure of multiple statins. Thus, the formulary drugs cannot be tolerated. In addition, a history of successful use of Livalo for several years was provided.

The appeal letter does include the information to justify the use of Livalo.