Diagnosis: Acute myeloid leukemia (AML).
Treatment: Chemotherapy.
The insurer denied Xospata.
The denial is upheld.

The patient is a male with FLT3 positive acute myeloid leukemia (AML) who underwent stem cell transplant. He has received chemotherapy in the past. Xospata was given to the patient for maintenance treatment.
At issue is the medial necessity of Xospata 40 milligrams (mg) tablet (tab).

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Xospata 40 mg tab is not medically necessary for this patient.
According to National Comprehensive Cancer Network (NCCN) guidelines, the recommended agent to treat AML after allogeneic transplant for maintenance is Sorafenib. Xospata is indicated for relapsed or refractory AML in adult patients with a FLT 3 mutation. There is no documentation of this patient being relapsed or refractory.
Therefore, the requested service/treatment of Xospata 40 mg tab is not medically necessary for this patient.