Diagnosis: Multiple Sclerosis
Treatment: Vumerity 231MG (milligrams) OR (oral) CPDR (capsule delayed release), pre-service
The insurer denied the Vumerity 231MG OR CPDR, pre-service.
The denial is upheld.

The member is a female with multiple sclerosis (MS). She has tried and could not tolerate generic dimethyl fumarate. The provider is requesting Vumerity. This was denied coverage as the member has not tried and failed the preferred agents. The provider has indicated that none of the preferred agents are appropriate.

No, the proposed treatment, Vumerity, is not medically necessary.

There is no reason the member cannot be treated with the preferred formulary agents for her condition. Anticipatory side effects such as future neuropathy do not preclude the use of any of these medications. To complete an eye examination and laboratory studies before initiating a medication does not represent a significant burden, is not a realistic reason for significant delay, and therefore does not preclude the use of any of these medications. Anticipatory non-compliance due to the member's unwillingness to inject a medication does not preclude using the preferred medications. Co-morbid depression is not an absolute contraindication to using any of the preferred medications. All of the preferred agents are FDA (Food And Drug Administration) approved for her condition based on high quality clinical trials published in the peer reviewed medical literature (McGinley, et al). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Vumerity relative to the preferred agents. There is no evidence that switching to a preferred agent would jeopardize her clinical stability.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.