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202204-148642

2022

Healthfirst Inc.

Medicaid

Endocrine/ Metabolic/ Nutritional

Pharmacy/ Prescription Drugs

Medical necessity

Overturned

Case Summary

Diagnosis: Endocrine/Metabolic/Nutritional.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Diazoxide.
The denial is overturned.

The patient is a female with non-insulinoma pancreatogenous hypoglycemia. She has had recurrent hypoglycemia requiring intervention from family members. She has undergone a 72 hour fast, which confirmed hypoglycemia. Imaging has not revealed an intervenable source. She has tried and failed acarbose. Request for diazoxide is under review.

The health plan's determination is overturned.

This request is for diazoxide for the treatment of hypoglycemia. The prior request was denied as the patient has not tried and failed Gvoke. Gvoke is a form of glucagon and is a treatment for severe hypoglycemia. This patient has recurrent hypoglycemia and requires diazoxide to prevent hypoglycemia. Diazoxide functions by lowering insulin secretion. Gvoke is not an appropriate alternative as it does not lower insulin secretion and is only Food and Drug Administration (FDA)-approved for the treatment of severe hypoglycemia. Gvoke does not prevent hypoglycemia. Without diazoxide, this patient will be at ongoing risk of severe hypoglycemia, which can cause seizures and be life-threatening. Therefore, the requested diazoxide is medically necessary for this patient.

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