Diagnosis: Epilepsy
Treatment: XCOPRI 12.5-25MG (milligram) Tab (tablet) DS PK (dose pack), pre-service
The insurer denied the XCOPRI 12.5-25MG (milligram) Tab (tablet) DS PK (dose pack), pre-service
The denial is overturned

This is a female who carries a diagnosis of primary generalized epilepsy for which authorization of coverage for treatment with cenobamate is sought.

The plan should cover the proposed treatment.
The proposed treatment is a rational escalation after a number of trials of first-line treatments, in the setting of clinically and electrophysiologically confirmed refractory epilepsy.

The requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.

The patient has undergone treatment with first-line management approaches, and has demonstrated both intolerance and insufficient clinical response despite treatment escalation. Without further escalation the patient risks future seizures that could develop into status epilepticus with associated sequelae that include disability and mortality secondary to SUDEP (sudden unexplained death in epilepsy).