202301-158260
2023
Healthfirst Inc.
Medicaid
Infectious Disease
Pharmacy/ Prescription Drugs
Medical necessity
Upheld
Case Summary
Diagnosis: Human immunodeficiency virus
Treatment: Serostim
The insurer denied Serostim.
The health plan's determination is upheld.
The patient is a male with human immunodeficiency virus (HIV), anxiety, depression, and crystal methamphetamine abuse. It is stated that to have wasting and hypogonadism. At his visit on 3 months prior, the patient's Vital Signs were: Height 174.6 centimeter (cm), Weight 88 kg (kilograms), blood pressure (BP) 120/72, Pulse 70. The calculated body mass index (BMI) was 28.86. Medications at that time were Dovato, Androgel, Tadalafil, Acyclovir, Trazadone, Fish Oil, Valerian, and Somatropin (Serostim). Exam noted the patient to be well nourished and well developed. In the assessment and plan, it is listed that the patient has Wasting Disease and notes patient history of weight loss and to continue Serostim. The note also notes BMI "above normal" and that the patient was counseled on maintaining a healthy weight by healthy eating, portion control, and exercise.
Serostim is not medically necessary for this patient.
The request for the medication appears to be based on the patient's subjective feeling of improvement in energy levels and alleviation of his neuropathic, carpal tunnel, and cubital tunnel symptoms. However, he does not meet the approved guidelines for use of this drug. He is also most recently noted to have a BMI "above normal" and was counseled on healthful diet and exercise to maintain a healthy weight. He does not currently have wasting syndrome and his BMI is > (greater than) 27, so he does not meet criteria for continuation of therapy. In addition, the records do not provide a pretreatment BMI and there is no indication that he has failed any alternative therapies (though noted that he has been diagnosed as hypogonadal and receiving Androgel).
Based on provided documentation the request for Serostim is not medically necessary for this patient.