Aubagio Case Study

The carrier has denied coverage of the replacement insulin pump (E0784), as the requested service does not meet criteria for medical necessity. There is a letter from the carrier to the member dated 04/27/2016, which states in part:

“The medical necessity criteria for coverage have not been met in this case. As a result, we are unable to

This writer met with the patient to address the conflicting issue with his medication. According to the patient, his PCP was prescribing him with his benzodiazepine medications; however, the patient says, " I had to seek a psychiatrist because it was only temporary." This explains the conflicting issues with the Rx Scripts on file. The patient started his treatment with his now psychatrist on 6/12/2017 and signed an ROI. Addressing picking up his medication from two different pharmacy, the patient was advise that he needs to be pick up his medication with only one pharmacy as it is required. The patient agreed to the terms and said, " I like CVS better than Walgreens. Sometimes they would my refill to Walgreens or whatever is closer to me,

The patient refused to sign the self pay estimate; because she feels that she should have been contacted before the having the test, and at the point she would not have had the test performed.

The carrier’s decision in denying coverage for the requested prescription Harvoni was not appropriate for the treatment of this member’s condition. This member meets criteria for treatment as recommended by the AASLD, the duration is limited and the treatment is expected to be effective for this member. The requested prescription Harvoni is medically necessary for the treatment of this member’s condition. The previous denial is

The carrier has denied coverage of continued occupational therapy from 07/29/2015 - forward as not medically necessary. There is a letter from the carrier to the member, dated 03/29/2016, which states in part:

The Amargosa project is located in Nye County, Nevada—approximately 100 km northwest of Las Vegas (population ~600,000 people), 35 km northwest of Pahrump (population ~36,000 people), and at coordinates 570100 mE/ 4036200 mN (WGS84, Zone 11S). The project currently comprises 142 unpatented mining claims covering 1150 ha (2,840 acres ).

Upon the passing of the Affordable Care Act (ACA), the United States health insurance policies have been reformed. As a result, many more Americans are eligible for Medicare health coverage. In addition, those previously under Medicare are affected by new changes to their policies. Among the recent changes are those that affect supplemental

If the Pharmacy is in the Network and the Drug is attached, claim rejects with Reject 70 - Plan Exclusion.

While the basic metal tier system may cover a good portion of the general care, there is a serious gap in the coverage for medicine. 54% of the silver health plans offered have a separate drug deductibles. In addition, 72% of those plans require coinsurance after that deductible for the highest tier drugs. The price for any treatment also varies significantly by plan and by state. This presents special difficulties for cancer patients who lack the information to compare different plans. Unpredictable prices for treatment exacerbate the financial burden of trying to pay for their medicine. One of easiest ways mitigate costs for cancer patients is to amend the way in which drugs classified. Under the essential benefits provision, all health care

Corey is a 35-year-old male who suffers from multiple sclerosis (G35). His symptoms include mild right leg paresis and deep tendon reflexes are brisk throughout, and difficulty with balance. Corey has been on Glatopa since July 2016, is stable and in need of this medication. The prior authorization was denied due to no recent documentation. There is documentation attached with this appeal. To deny him coverage of a therapy that is working for him is negligent and unethical. MS patients should have the right to treatment regardless of disease duration or level of disability, to help improve their quality of life. Without this treatment, I fear he will progress and relapse, experiencing debilitating pain as well as quality of life

Realizing that Part A had some flaws, and could prove to become very expensive for those patients who were chronically ill and might not be able to afford treatment within the given coverage guidelines of Medicare Part A, CMS devised an optional Medicare Part B program, commonly referred to as “physician services”.  Medicare Part B not only adds additional insurance, but also covers other health care needs, particularly those not covered by Part A.  This Supplemental Medical Insurance (SMI) does not cover the services 100%, but rather 80%, where the beneficiary would only be responsible for the remaining 20%, also known as a coinsurance. (Lonchyna)

Unfortunately, Robert never had health insurance, due to his choice of employment, and his employers did not offer health benefits. Robert disregarded his health and avoided going to the Doctor for regular check-ups. In his late twenty’s Robert’s high blood pressure escalated to renal kidney failure that could not be a cure. Luckily, for Robert Medicare has an unusual clause in their insurance coverage; End Stage Renal Disease program for anyone who suffers from renal failure qualify for insurance since under the special status his age and income did not affect his eligibility. He received a kidney transplant and continues his health care routine by having dialysis a twice a week at Neomedica Dialysis Center. Robert’s attending physician Dr. Lang is

Net sales for the month ended December 31, 2016 rose 8.5% to $570k from $526k in December 2015. Bimba comprised 71.9% of net sales in December 2016 versus 70.3% of net sales in December 2015. Sales to S&S Cycle, McMaster, and D&N Bending exceeded prior year by $37k collectively. Returning customer Concentric added $6.5k in sales during the month.

“This article discusses how Medicare Carriers and Fiscal Intermediaries use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected to not meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the