Diagnosis: Gastroesophageal reflux disease.
Treatment: Dexlansoprazole Delayed- Rel (release).

The insurer denied coverage for Dexlansoprazole Delayed- Rel (release).

The denial is upheld.

The patient has a diagnosis of esophageal reflux disease and Barrett's esophagus. The diagnosis code that was submitted was for K21.9 which is Gastroesophageal reflux without esophagitis. It is reported that the patient has been on Dexilant (Dexlansoprazole Delayed- Rel (release)) for several years and that previously multiple other medications had failed. The submitted information for review does not specify which medications have been tried and failed. The formulary alternatives include esomeprazole, lansoprazole, pantoprazole, and omeprazole.

UpToDate has an article titled "Proton pump inhibitors (PPI): Overview of use and adverse effects in the treatment of acid related disorders." The article states that PPls are similar in structure and mechanism of action although there are differences. However, the magnitude of these differences is small, and their clinical relevance has not been established. A systematic review of 12 randomized trials examining the relative effectiveness of different PPI doses found no consistent difference in symptom resolution and esophagitis healing rates.

This patient has a diagnosis of gastroesophageal reflux disease and giving a PPI is appropriate. However, the information that was submitted for review does not show that the patient has tried and failed the multiple PPI medications that the insurance company has offered. The Up To Date article does not support the assertion that one PPI is superior in esophageal healing as compared to the others. The formulary drugs are not likely to cause an adverse reaction. The medical record does not document which PPls have been tried and failed. It has not been shown that Dexilant is more effective than the other proton pump inhibitors.

The formulary drugs are not expected to cause adverse effects.

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The carrier's denial of Request for Formulary Exception for Dexlansoprazole Delayed- Rel is upheld.