Diagnosis: Sickle Cell Anemia
Treatment: Ferriprox
The insurer denied the request for Ferriprox.
The health plan's determination is upheld.

The patient is a male with a diagnosis of sickle cell anemia who is receiving chronic monthly blood transfusions. He has had complications to include acute chest syndrome, splenic sequestration, and multiple vaso-occlusive crises. Due to the chronic transfusion therapy, he has been having issues with iron overload. He has recently been treated with Deferasirox at a dose of 17 milligrams per kilogram (mg/kg) per dose, and this has not been effective in lowering his ferritin levels and providing optimal chelation. He had a liver iron concentration measured at 6.1, and at that time he was not receiving any chelation therapy. Ferriprox was requested and denied by insurance, so he was started with Deferasirox at that time. The provider is again requesting authorization for Ferriprox.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment, and in the best interest of the patient.

The requested health service/treatment of Ferriprox is not medically necessary for the patient. Deferiprone can be used. The patient has iron overload from scheduled monthly blood transfusions as treatment for his sickle cell disease. He has failed treatment with Deferasirox and his provider is currently recommending therapy with Ferriprox. As part of the prior authorization request, there is a notation that Deferiprone was denied for this patient. The reason for this denial is not provided. However, at this time, the request for Ferriprox is being denied, as the provider has not documented trial and failure of the generic Deferiprone product.

While this patient requires chelation therapy, there is no clinical documentation to support the need for the brand name Ferriprox over the generic Deferiprone for the patient. The patient otherwise meets the criteria for chelation therapy given the level of iron overload present in his system. Without clinical documentation to show that Deferiprone has been in fact tried and failed, Ferriprox cannot be approved at this time.

The health plans determination of medical necessity is upheld in whole.