Diagnosis: Type 2 diabetes mellitus, stage 4 chronic kidney disease, hypercholesterolemia, and hypertension (HTN).
Treatment: Farxiga

The insurer denied the Farxiga.
The determination is overturned.

The patient has a history of type 2 diabetes mellitus, stage 4 chronic kidney disease, hypercholesterolemia, and hypertension (HTN).
The patient's provider states the patient cannot take metformin or Jardiance due to her estimated glomerular filtration rate (eGFR) being less than 30. The provider would like to prescribe Farxiga which is a sodium-glucose co-transporter-2 (SGLT)-2 inhibitor in the setting of chronic kidney disease (CKD). Farxiga is indicated to reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular (CV) death, and hospitalization for heart failure in adults with chronic kidney disease at risk of progression. It has also been shown to reduce the risk of hospitalization for heart failure in adults with type 2 diabetes mellitus and either established cardiovascular disease or multiple CV risk factors. The patient has a creatinine of 1.91, an eGFR of 29, and a hemoglobin A1c of 12.2. The health plan denied Farxiga as they require therapeutic failure (after a 3 month trial), contraindication of intolerance to Jardiance in order to approve an alternative such a Farxiga. At issue is the medical necessity of Farxiga.

The Farxiga is medically necessary.
The formulary alternatives are Metformin [generic Glucophage, Glucophage XR] and Jardiance)
The patient has an eGFR less than 30. Both metformin and Jardiance are not approved for use with an eGFR less than 30. Farxiga would therefore be medically necessary as the two alternative medications are both medically contraindicated.