A review of the records reveals the member to be an adult female with a birth date of 07/30/1960. The member has a diagnosis of psoriatic arthritis. The member’s treating provider, Lisa Allen, MD recommended the member continue treatment with Otezla (Apremilast).
The carrier has denied coverage of treatment with Otezla (Apremilast) as not medically necessary. There is a letter from the carrier to the member dated 04/08/2016 which states in part:
“Based on a thorough review of the information provided, a determination was made to uphold the denial for coverage of Otezla. You requested a medication called Apremilast OtezlaTablets) to treat your psoriatic arthritis. This request for coverage of Apremilast OtezlaTablets) remains denied because according to the information provided to us you do not have a documented inadequate response or inability to tolerate a traditional DMARD and two preferred/formulary targeted immunomodulators, if available (e.g. Humira, Enbrel). This determination was based upon Capital BlueCross' Medical Policy Criteria regarding Medical Necessity Criteria for Pharmaceuticals: Biologic Disease Modifying Antirheumatic Drugs (DMARDS) RXCRIT-4. External case review by a board certified Rheumatologist was obtained, who concurred with
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Patient currently takes Sulfasalazine and Ibuprofen, but still with only partial control-should have better psoriatic control. Patient has also tried Plaquenil (allergic), Prednisone, Celebrex (allergic), Ultram, Meloxicam, Flexeril, and Depo-Medrol. Patient cannot take Methtrexate or Arava due to alcohol use. Patient has fear of using Humira and Enbrel due to having to give self-injections and all the potential side effects that she has read about; however, patient disease is not controlled and we need to get her on a medication that will control her disease that she will actually take. Patient still with joint pain and swelling in both
Anne Morell is a seventy-four year old female with a past medical history of hyperlidemia, hypertension, osteoarthritis, osteoporosis, diabetes mellitus type 2, renal insufficiency, Charcot foot, and osteomosteomyeltits. Anne has a history of osteosarcoma treated in 1996 with surgery, chemotherapy and radiation. Anne also has a history of breast cancer, diagnosis in 2003 treated with radiation therapy. Anne past surgical history includes tonsillectomy in 1962, removal if osteosarcoma of left thigh in 1996 and lumpectomy of left breast in 2003.
Three examples on why a claim may be denied are: 1. No preauthorization for non-covered benefits, 2. Processing errors on physicians end and/or no sufficient supporting documentation on why a certain procedure was done for a certain diagnosis, and 3. Incorrect CPT or ICD-9 codes. An EOB can prove a certain service or procedure was denied for the reason specified will be included in the “remarks or description field” in the
In some instances, the pharmaceutical industry in the United States misleads both the public and medical professionals by participating in acts of both deceptive marketing practices and bribery, and therefore does not act within the best interests of the consumers. In America today, many people are in need of medical help. In fact,the Federal Trade Commission estimates that 75% of the population complain of physical problems (Federal Trade Commission 9). They complain, for example, of fatigue, colds, headaches, and countless other "ailments." When these symptoms strike, 65% purchase over-the-counter, or OTC, drugs.
Patients must exhibit 4 for the following: “malar rash, discoid rash on the cheeks, photosensitivity to sunlight, painless mucocutaneous ulcers, nonerosive arthritis of at least two joints, renal dysfunction evidenced as proteinuria or cellular casts, positive serum ANA, neurologic disorder such as seizures or psychosis, serositis as evidenced by pleuritis or pericarditis, hematologic disorders, and immunologic disorders” (Robinson, Sheets Cook, and Currie, p. 632). A patient that does not have four of the qualifying criteria for SLE will be labeled “incomplete” or “latent” SLE (Bernknopf, Rowley, & Bailey,
Although Pfizer was not required to warn the public and Kline, they were responsible for warning physicians. Pfizer dismissed Kline’s Complaints pursuant to Federal Rule of Civil Procedure 12(b)(6), which successfully dismissed Counts I and VII. Motion to Dismiss under Federal Rule of Civil Procedure 12(b)(6) “for failure to state a claim for which relief can be granted.” As the Plaintiff, Kline should have provided several sets of proof in order to support his claim and be granted the relief. Kline failed to provide the Fact Sheet and Authorization forms under the Joint Coordinate Plan.
Kelly is a 48-year-old female who suffers from plaque psoriasis (L40.0). Kelly’s symptoms include scattered, confluent papulosquamous plaques with silvery scale located on her scalp, buttocks, hands, arms ears, abodomen and legs. Kelly has tried and failed various treatments including numerous topicals, betamethasone, and Otezla. The denial letter states that Kelly does not have a history of failure, contraindication, or intolerance to Enbrel or Humira. However, Kelly has been on Stelara treatment waiting on authorization from insurance and is showing an overall relief of her symptoms for the first time in her life. It would be ill advised and completely unethical to discontinue the Stelara due to your denial as this medication is clearly
ACA Policies and Resolutions. (2004, October). Corrections Today, 66(6). Retrieved April 12, 2005, from EBSCOhost Web site: http://web9.epnet.com/citation.asp?tb
Healthcare providers must make their treatment decisions based on many determining factors, one of which is insurance reimbursement. Providers always consider whether or not the organization will be paid by the patients and/or insurance companies when providing care. Another important factor which affects the healthcare provider’s ability to provide the appropriate care is whether or not the patient has been truthful, if they have had access to health, and are willing to take the necessary steps to maintain their health.
Another downfall to HMO coverage is selective-contracting. This is a process where hospitals deny treatment to patients because their...
Dryden-Edwards, Roxanne MD, Conrad Stöppler, Melissa MD. Medicine net Inc. 17 June 2009. 23 February 2010 .
According to Michigan Physical Therapy Act(MPTA), “ consult with the health care professional who issued the prescription for treatment if the patient does not show reasonable response to treatment in a time period consistent with the standards of practice as determined by the
Polypharmacy is the “concurrent use of several differ drugs and becomes an issue in older adults when the high number of drugs in a medication regimen includes overlapping drugs for the same therapeutic effect”(Woo & Wynne, 2011, p. 1426). The patient is currently taking several medications that can potential interact with each other, perform the same therapeutic effect, and creating side effects. The following is a list of her medications and their indications:
As this case study is evaluated we look at who is involved. This case involves a 44 year old patient this is the plaintiff in this case. The issue began when the patient noticed bumps on his wrist; one may think that this
The ad is "in Treatments withheld under this policy might include antibiotics to treat. infection, medicines for fever reduction, tube feeding and hydration. kidney dialysis or ventilator support. Of course, physicians have never been -- nor should they be -- required to. provide medical interventions that provide no medical benefit.
Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit.