[it UnitedHealthcare' 01/06/2017 RE: Coverage Review Denial Patient: ALISA ERKES Physician: JORDAN TATE ALISA ERKES GA 30080 Date ofRequest: 01/05/2017 Date of Decision: 01/06/2017 Dear ALISA ERKES: fittfl 1.30 7114557 nine k'diji shidi'i' kojl' hadillnih lemon--4555 pm oblmaasiflmda en Espariol,l1:me :1 Lion. 14553 Fan 51 ruleng sa'hgaiog mg LEOOJI ms>> This letter is to inform you that we are unable to approve your physician's request for coverage of BUTRANS. The request did not meet the conditions necessary for coverage for tile following reason(s). The request for coverage for Butrans is denied. This decision is based on health plan criteria for Butrans, This medicine is covered only if: The requested medication is not being used for any of the following: For acute pain. (ii) For opioid dependence, (2) You are not receiving other long-acting opiolds concurrently. (3) One of the followmg: You have a history offailurc, contraindication or intolerance to a trial ofat least one of the following (drug. dose, duration and date of trials must be provided): (A) Tramadol extended-- release (generic Ultram ER). (B) Morphine sulfate controlled release tablets (specifically generic MS Contin). (ii) OR you cannot swallow any oral medications. The information provided does not show that you meet these criteria. This case was reviewed in consultation with Dr. Christopher Sivak, board certified in internal medicine. Your UnilodHealthcare prescription drug program is administered by Optume. For certain drugs. more information is needed to determine coverage eligibility. In these cases, your physician must supply the additional information needed to determine if the coverage conditions have been met. A letter was sent to inform your physician ofthc decision. Your physician can discuss the clinical rationale for this denial with the physician reviewer by calling 17300.71 1.4555. Please direct questions about prior authorization to Optume at 1-800-7114555. Please direct questions about your pharmacy benefit plan the Customer Service number on your ID card. rye UnitedHeaIthcam' 0 Box 30573, Sail Lake City, UT 841300573 January 27, 2017 AI ISA ERKES TRANSACTIONW. W027l3040l3 INSURER: RE INSURANCE COMPANY WA ID at: PATIENT: ALISA ERKES PLAN PROVIDER NAME. PHARMACY SERVICE DATHS) NA - PRE-SERVICE MEDICATION CLAIM AMOUNT. PRODUCT: P03 7 POINT OI- SERVICE Dear Alisa Erkes: We rcvtewed ilie urgent request to tiur prcuous decision regarding the medicatitints) that you ivill c. We undeislund the appeal to state that your requested this I'tir iteatmenr of your condition. Explanation of Decision We carefully reviewed the documentation submitted, our payment policies and the limitations, exclusions and other terms of your Benefit Plan, including any applicable Riders, Amendments, and Notices. We continued, however, that this mud' dtion(s) is not eligible for payment as you requested. You are responsible for all costs related to this inedicaiion(s), According to Section Exclusions in the Benefit Plan Outpatient Prescription Diug Rider: A Prescription Drug Product that Contains (an) active ingredienlls) available in and 'I'hcrapeutlc'dlly Equivalent to another covered Prescription Drug Product. Such determinations inny be made up It) SIX times during calendar year, and we may decrde at any time to reinstate Benefits for Prescription Drug Product that was previously excluded under this provision. Medical Necessity definition: Determtnatmns Ur decisions that are (or which could be considered to be) covered benefits, including dctenninations defined by the organization; hospitalization and emergency service's lisied in ihe of Coverage. Evidcnce diciiviitage or Summary ofBeiicfits; and care in medication that could be considered covered or nonvcovered, depending on the Circumstances. Medications are medically necessary when, using generally accepted standards of good medical practi in the medical community, the medication is needed to diagnose or effectively treat a medical condition. The determination is based on review by appropriately licensed clinical staff. Only you and your physician can make decisions about your medical care. u. Felise S. Zollman MD. UnitedHealthcare Medical Director, SpeCialiZing in Brain Injufy Media?? reVieWCd Your appeal This dedision ,was made based on UnitedHealthcare Pharmacy - Prior Authorization/Medical Bupl-enorphine Products (Pain Indications) - Excluded Drug Criteria. Dr. Zollman deterinination is as follows: You asked for coverage for Butrans to treat your chronic pain. We reviewed your clinical notesand health plan documents. Based on this review we have decided to uphold this denial. Approval of continued use of Butrans requires that your doctor provide us with documentation of continued op101d treatment goals, a treatment plan that includes the use of a nonopioid analgesic and/or nonpharmacologic intervention, documented meaningful improvement in pain scale score, substance abuse screening, rationale for not and identi?cation of any other tapering down your pain medication dosage, mental health screening, I . controlled substances also being prescribed for you. Further your doctor has to attest that information provided is true and accurate to the best of their knowledge, and they understand that UnitedHealthcare may perform a routine audit and request the medical information necessary to verify the accuracy of the. information provided. The records provided do not indicate that you meet these requirements. The denial is therefore upheld. Your request was reviewed by a Board certi?ed Neurologist. This is only an interpretation of your Health Insurance Plan. It was based on the information that we were given and the language in your health plan. This is not intended to in?uence any decisions about your medical care. You, a physician (provider), your representative, or someone acting on your behalf has the right to receive, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to your appeal as well as copies of any internal rule, guideline or protocol that we relied on to make this payment decision. You, a physician (provider), your representative, or someone acting on your behalf also has the right to receive, upon request and free of charge, an explanation of the scienti?c or clinical judgment that we relied on in making this bene?t decision, as well as the diagnosis or treatment codes, and their corresponding meanings. To request copies, submit a written request, separate from an appeal request, to: Central Escalation Unit Appeal Document Request PO. Box 30513 Salt Lake City, UT 84130?0573 . . . . . We Will ful?ll this req Within thirty (30) calendar days of receipt. Please understand that the request for information will not change the time that you have to ?le any subsequent appeals. a We will retain documentati of this appeal request for four (4) years. Within this time frame, you, a physician (provider), your representati e, or someone acting on your behalf may request a copy of the documentation, and we will provide it to you wit 'n 30 calendar days of your request. If we uphold a clinical appeal, your provider may, within 10 working days of the appeal denial, request a review by a specialty provider by submitting a written request showing good cause for the additional review. We will complete our review within 15 working days of the request.