Anite te Cro Anthem.) c/o 4700 North Hanley Street Suite B ° Bry . St, Louis, MO 63134 BlueCross October 13, 2017 ATTN: Confidential UM Information 2017135270.499 CID BCM-UMCEA Dr KEDAR DESHPANDE Date Created: 10/12/2017 Reference Number: 41204052 Member Name: Medication: Nucynta Er Tab Er 12H Provider: Or. KEDAR DESHPANDE Denial Reason: MEDICAL NECESSITY Dear Dr. KEDAR DESHPANDE: 1) 2M Serviees, inc. provides utlization management Services for Anthem Blue Cross. ae ergland how your health plan works so you con get the most from your Panels. Certain mecicetions within your health plas fequire review to see if they ore the meta crption of benefits. Coverage for he recusetcy medication is "fee Medication does not meet the enitena of “mediece Necessity” under your pion cf benefits. Medications that are considered nor medically necessary are not the deego"sing to your description of benefits To assiat cor medical director in making fs decision we have pul a process in place to send information about the service to 8 ‘ical reviewer with appropriate credentials Based on their opinion, we have determined that Coverage for the requested medication is aenied. eu litical reviewer concluded the folowing: because we did not See certain details about your use and treatment. We see that this is 4 request for a called Nucynta extende release 100mg tablet for your use {pain severs enough to require daily, around the clock long term, Opioid treatment, intervertebral disc displacement of lumbar fegion). We may consider ie SPproval of this drug after trials of TWO certain other preferred long-acting drug first (triaf Meaereterred generic lang-acting agent such ae fentany! paich, levorphanol methadone, Methadose, generic marphine sulfate extended release, generic tramadol extended release long. acing pent onded release, hydromarphone exiendoa eae AND one preferred brand PA (Rlgracting agent such as brand Oxycontin) We aa Rot recsive or we did not see information that you had a poor response ar did nat tolerate two of these other drugs first or that you Cannot use them for medical reasons (due to concomitant Clinical situations Such as known hypersensitivity to any ingredient in the preferred agents which is Not also in the requested "on-preferted agent), We based this decision on your heaimn Plan's prior authorization criteria seca AA aes it the trade name of Bue Cross of Gelforna Independent Asgogalion ANTHEM is a registered ragsmark chaninee Me and symbo) are registered marks of Ins Bice 1809 of the Blue Cross ‘ance Compenies, inc The Blue Cross none ‘them UM Services, Ine. 1s a separae SnaLen peace aneh "PANY FOMNG Ulzaionreven services On benst Gr MGns en ve Cross, 2orT10130G NOG. wa UMCPADP_ WLP WLW0a 1315 UTR_UMCPADP WLP WEE nnfug @? 2814 13:18:45 ATAT/CVS Pharmacy -> Page 862 ee Date ogiorzar4 i BMOLINA’ EAUTHCARE Member ‘Supe Denial Letter Provider JIMMY HENRY Member Date of Requess 8105/2014 Dear Meinber mnartee acres rae! or autho of HYDRO ER 20M0 CAP cd o80672014 fer he shove named | Facies er te nm sovied by We requesing provide, ie blsbed noted oe cites or aude forthe above noted services) haven teen metal sine Theehire tov ones ee denied Request far ZYHYDRO ne medical ree rue The request doesnot mest Molina Pharmacy guidelines for 2YHYDRO ER. 4 documensation of «vrerapevte falar on, comtpirsicavien oo ox lowes w acton your beball sal. You must ak or an appeal rawer win 5 ealondar days of your ls 802-4268 of for hearin sino ea be faxed fo 1-866-713-1891, sent le te akdiess below or suton:ted va di interet at www Moluatleaitcre corm (Selec 78 ten “Ch,” then ‘he "Mem ber Grievance Appeals Coordinator Molina Healthcare of Ohio P.O Box 349020 Columbus, OF 43234-5020, tate your nam, member ub, restors for appealing telephone number where we can AS any anforiatin yo. want to atach such au mesial ecards ox provider len We aac ae proce, Meurer ef tus ut an what he oF sense to do toappel te dacaton you mune rect agree ameoee ess to mson you thal fer the appeal you mu allwxdas ramon You PC REM Wau writen comment, dacunsis, rae infomation elated he es aan ee eso your apes, sihading woratn regardug the Page B62 eo Date cer0s2014 ' MOLINA: EALTHCARE Member Subjec: Denial Letter Provider mo. Member (D> Date of Request os/o42014 Deas mare patie request fr atorzaion of ZOHYDRO BR 20M0 CAPS dated (0804/2014 forthe abovs named fee an the tkermaton proved bythe requsing provides ie en ‘odieal necessity enters or [uidelaes forthe above noted services) have not bean acct ten time The thus request has been denied. } Hapa eet ome nat met Moka Pharmacy guelines, There it ce medical "selauen ofa therapeu failure on, containdicrion mee nk "formulary low cost alternatives; PHONE ER TABLETS In order toconsider sppsova! ct ety formulary altrratives "you don't agise wid this actin, you, your provider, somone you have allowed to aet en your behalf Wnou eran Cut deesinfaton Tha reques: called tapes! You mat cok fe appeal ing dat ofthis notice. We will gnc you antananer witun 3 kee Oo gfle? im TT you éon tagroe with this aso und wane a impaired TTY'Ohio Rely 1800. S0:0750 6 tring to the address below or wubrutted win “Member,” chen “Oho,” then "any “een at | -80%612-2168 oF for hearing also can be faxed to 1-866-71341891, ent in ‘vin éowialfeltheare ecm. (Select Appeals Cooudirarr Melina Healtoar of Ohio PO. Box 349020 Columbus, OH 43234-0020 Make sur to inciuste your mane, sietnbr eumber, ssors for appealing, a telephone’ nesiber where we sun tna) 228 al ay information you wart atach ach av meal ests oe EHO We abo iive ror ges Boter of th actcn and wt hear as need to dota uteal eee IE you want your eee sito. of someone else oat on your tale fe ape yor snes ve dus in wring. You pave the nghe to sir writen sommenis, ocumeria, cr we infra related to che appeal You use teat asses copes fall documents ridtadioyous ope inciuding informauen regarding the scaly cf the provider: who reviewed you spp * Joaren seizing cory of he benefit provitony, amet guidelines ad cteia ned oranda this dena Geewon by sending a equ to ah ds iene shove or by asics by telephone Molise Healthoare of Oh # P.O Bax 349020 6 Columbus, OF 432349020 worw MoluaHealtiare com Mito-t435 v3ug 85 2014 12:34:41 ATRTVCYS Pharmacy -> Page 883 fe chet cg mt ae uP 01 lends cide your ppl cold senously rk JOE TE ec health eluding yor being abe to each kee, orga bak once neree Function you or Foun (wid Bone tig when akg for an ppl ewe agro, we wills ee decision sooner (wit Uyee working diye . 8 BokY ta for a whl & had abeady approved you to receive, you can Ue ation. You have te right tokeep $e miaomLUed uml we make ou decor on appeal To keep getting the seme you heat Sik malig date of ths nce othe efecuve data of he ata "pheal te action and keep get the ‘Std acc Pecan Pt te sevice he Oho Depa of Nadiad (ODS) cee ae oe ‘sed somenlybecaute of Faulent bahar io on yo pos an appeal eiier wiht 15 working days of he # Youslso hava ihe agin to (ODM) willceentestwe on the encioted form w Gia hearing, A heuing office from the Ohio Deparmnert of Medicaid acs 4 "et decton. IT you want state hearing, you mist follow the Aes ‘he mauling dete af tis naice Aye * ERA mith deitnedon bu youre unapoy with he step we ander your Provider took to ime he dvision, you ls an contact tll us why you we weap your rats provtder would lke calling the Molo Hesitieare Pharr Friday weitun seve cys fron nul cision wih physi eviewer, he or sho san oso by &t [800-642-4168 from 9:00 0m, to 500 pm. Monday Brongn the dent ntiietion, ‘saltheare com or call Member Services at 780 of 711. Represenative ae committe to the halp You sed representative willbe available banat you fon sole this aiormuion preted seep (RU, specil help ea we provides pase conact Member Services for help at no ation ray, i English of an your primary ages or wether ways IE your vision wey saeiets Ou: Nurse Advice Line open 24 haus, seven cays a weck Registered muses will help you undentand ‘ud ianage your health and medical conditions 1-888-275-8750 1-866-648-3537 Expaol) 1-866-735-2929 o¢ 713 (TTY) sia Highs Hons, Kos Pulp Hans Pharm Passraey Director aacy i ag Molina Healtheare of Ohio # P.O. Box 349020 » Colunbus, OF 43234-5020 i MolinaHealtscace corn MitO-1435 oaSep 22 2814 14:28:88 ANAT/CUS Pharmacy -> Page 82 eo Date osre2014 t BMOLINA HEALTHCARE Member Se Subject Denial Letter Provider KEDAR DESPA: Member 1D) Date uf Request D5/1972014 Dear Member LGO BR SMG TAB dated 0919/2014 for the above he information provided by she requesting provider, the established meine 63 for he above nated service(s) have not been met et this time Thechice request does Pharmacy guidelines for EXALGO ord documentation 1, contraindication 10 oF intolerance to “YMORP TABLETS, 7 L&ASE CONSIDER TITRATING HONE ER tn erder * approval of this medication we shh (Hs action, you, your prover, your legal representative, of someone you or vour behalf can ask thal we chunge out decisionvaction This request sialon antes! You must ask foran appeal within 50 davs ofthe maling date he sree ‘1 give you an answer within 1S calendar day’ of your request for an uppes] © (Dope don’ ausee with this action end want an appeal, please cell ws at 1-860-642-4168 or for bearing ump ‘YiOhio Relay. Wines. 713-1891, sent in writing othe address below ot submitted via the Intent sp Grin MolinsHeattheare com. (Select "Members," hen “Ohio.” then "Quali" tren Grievance") Appeals Coordinator Molina Healtheare of Ohio P.O Box 349020 Columbus, OH 43234-9020 {prite Pea you must telus tis in wring You have the igh tosubene acien comms SRARENS, oF other formation related tothe appeal You also have the roy peal att lated to your appeal, nlating information segarding the sasinceneng 2 specialty of tke providers who reviewed your appeal,Sep 22 2814 14:29:88 ATAT/CVS Pharmacy -> Page 883 * You may obtain scopy of the Benet provisions, weatment guidelines and eiteria used to render by reepteet#ton bY sending a request to wa headless fetid above or by contacting us by telephone *[E¥ou or your provider belive that wating up to 15 calendar days to decide your appeal could scicualy sk you life or heath, including your being able o reach, keop,o gt back sour ‘maximum function, you or your provider should tells this when asking for tn appenl Toe ‘eres, we will expedite or make a decision sooner (within three warking dey) + thwe are going to reduct stop for a While, oF end a service we had already approved you to parse feu appeal the aston You have the right to keep geting the sence aa apnaoved dnl sve make our decision on your appeal To keep geting the service you mus seo appeal either within 15 working days of the mailing date ofthis notice ar the effecanee Fen sat tppeal the action and keep gating the service, you may have to pay Tor the sence srs Ohio Department of Medicaid (CDM) decides that we acted eorrecly because of aedcead Dehavior on your part * vou have questions or need additional assistance, you may contact the Ohio (aeparttient of Medicaid Consumer Hottine online st hupliomb.com or by phone at (800) 324-8680 or for hearing impaired TTY /Ohio Relay (800) 292-3872 oF 711 2, have the right fo ask for a state hearing. hearing officer from the Ohio Department of Meee ODM) wil decide if we made the right decision Ifyou want a state hearig, you mest ‘bllow the directions on the enclosed form within 99 days afler the mailing date ofthis nowee sb mires with the desisisnsetion bat you are vahappy withthe steps we and/or you provider wok wrrahe the decision, you also Ean contact usw tell us why you ne unhappy ofr Healing provide would tke to discus this denial deision with the physician reviewer, he ot she +) de 30 by calling the Molina Healthcare Pharmacy Department at 1-800-642-4168, ext irateatiam #20 4m to S40) pm Monday through Friday within seven days from the date ofthe denial Seoutavs wry questions, please visit our website at www MolinaHeslihcare com or call Member Remit a | 400-642-4168 o for hearing impaired TTY/Ohio Relay 1-800-750-0790 or 711 Aeoreseniatves ere committed fo ireaing you with respest and getting you the help you need. A Feoresenaurve wll be available oasis you trom 7am. 19 7 pm. Monday through friday you have uny problenns in reading for help ano cas: to you Wee English ori your primary lang * understanding this information, please contact Member Services *eip to explain the information or provide the information orally, im We may have this information printed in certain othe languages ot tm ther ways If your vision and/or hearing are impaited, special help ean be provided In gdion, eur Nurse Advice Line is open 24 hours, seven days a week Registered nurses witl help you understand ang manage your health and medical conditions 1.888.275.8750) 1-366-648-3537 Espatol) 1-866-735.2929 or 711 (TTY) Sincerely Kinbal, Baylis Baga Kimberly Broyles-Kpogti Pharm 19. MBA, PMP. Pharmacy Directorfog 8? 2814 13:18:45 ATAT/CVS Pharmacy -> Page 862 Date avon Meriter Subject Deniat Letter Prowder TIMMY HENRY amber ID Date of Request (Os1087201« Dear Member mnarbey ests ee! or authonznuon of ZOHYDRO ER 20M0 CA? dated 080672014 fer the Hove named Mee sled othe infomation sovied by the equesing powder, ths euished cea Resessty citer or Sistine forthe above roid serve) havona benmetal atime Tice. tis onser hera e he rejues: doesnot mest Molina Pharmacy guidelines for 2YHYDRO ER. prof aherapute fl or, censineauon too nolan ta Cormulny ‘consider approval of ths mediemtion we need medion! short YOU provider, cr someone you aye allowed to acton your behalf wr des cedaston Thi equa salledan pea. You must ask for an appear aun 90 days of wie mailing she oft noice We will ive you an ewer wenn 1S calender days of your test for an appeal font agree with ts aetion ard want a please calls a 1.800%62.4268 oF for hears "Y'Ohuo Relay 1-80.50 also car be (ate 0 1-868-713-1891, sent un 255 below ot « # tnemel at ww MoundHeaithcare com (Select "then “Ohi,” then "vali," then "Mem ber Grieve Appeals Coscdinator Molina Healtheare of Ohio P.O Bax 349020 Columbus, OH 43234-9020 ovr nana, memiver nee, eaters for appealing telephone number wiete we ant attach auch as medical records or provide leters: We uae he oUF Bsr oft ution an! what be or se ae odo to ppt davon you mean provider, a lawyer, or sory aston your bell forthe appeal you must tellus ths in wns, You rare dee Gault writen comments, docunent, or aber infomation related tothe oppea Wares ave the right co aveess copies f al: documents rel \ opp, sicluding nfernaten regarding @ Salis a spectly of Ue providers who ev .ewed yous topos * AGE giz eopy ofthe benetit provisos, nestnet gules and onteria wed to ender th denial “eston by enc a request ous at the adress defied above or by conactng ust teopho Molina Healthcare of Ohio # P.O Box 349020 + Columbus, OH 43234.9090 ‘wow Molinatiealewe com .fus 85 2014 12:33:42 ATAT/CVS Phacnacy -> Page #82 eo ‘ ; 0 i MOLINA “ asa MOuINA Sie ste Deana ree Mamber iD Date of Requess 0870472018 — We have received a rages fer author zauon of ZOHY! ‘member Based on tie ion Dea 3 RO BR 20MO CAPS dated O8;04-201 oh provided bythe requeyig provider, Ui eau! 4 for the above named sted medical necessity crite oe uidelines forthe above noted vervices's) tuve nox been tus request has been denied ) Rave fey EXALOO BR ss denied, The request dot not mect Molina Phy { curd documentation of a dherapeute flue on, srtandectin: oon XYMORPHONE ER TABLETS. in order io conmidor approval of i 6 iv (urrulary alterativea ‘ agive wih this action, you, your provide, or scree ‘sk the we chunks our deeisionfection. This roqust scl AD\, sofhiaidascitnatng eran tare 2 spe me you have allowed 25 upped beta ou dant agroe wid this aired TTYOhio Relay 1-800. nig 1 Ui address below ors Members," then “Ohvo," then "us aty callus 1 -8004642-4168 of for earing De fanet to 1-866-713-1891, sent in feat www Ba then "Memon: Gr Appeals Coordinate Molina Heatncare of Ohio PO. Box 349020, Columbus, OF 43234-9020 MARS tr? nck your oa, mabe mur, reasons fo ap Toyo proves of ea ft wit una such av medal corse groves Ienen Weng oe provdde, Movie! Us action and what hoo she ner odo tw appeal is eseroe you want your your pe Fave he ghee Someone to et on your baal rte appeal yousstior eo ng You comments, docu ofall document ofthe providers who re ing, 9 elephone umber where we ex 3, ¥ other informatica related the appeal Youn 'o you appeal, eluding information regarding the svcd Your appeal alifcaicns and speci © ears bins ory oft beefi provinons, emma guidelins ard eieria ned oredr us deruat ‘esston by senling a cequst ous at hares identi shove o by ontacting ws by telephone Melina Heatncae of Oho # PO Bax 345020 » Columbus, O11 43234.8020 wor: Molinatfeliheae com Mio.135 oa41 ATAT/CVS Pharmacy -> ar ne vie bee tt wating upto 13 een ys dae your appeal could sero risk Yeu Mor bel inchucig your being able toric kam, rgttmck oc eer faction you or Soon (uit deal llth when ska for an appa agen, we wil nn ee dsisien soonet (wun dee working dae * dis are gong to reduce, sap tera wie or end aservice we areal theacton. You have the right w keep peau ti arr your appeal Ty mating date of Wus notice oF the effective dt service, you may have o pay for ie acted covet ie ifthe Oho Departinent ef Me behavior on your jet id already approved you to receive, you ean Se BNDIRLGd Ul we make our deesvon oo te sevice oN mata er an appeal eur within 15 wanktg don che lite action Ifyou appeal Ui acuon and keep geting be w3id (ODM) decides that we 7 Gato hve te rg. ak ar a at hearing, A hearing officer fom the Ohio Deparunent of Medicaie (ODM) wilicecide Fae made he ag on the enclosed frm w 5 day ae ‘he mailing date of tis notice sicten. Hf you want a state hearing, you must follow the drectons + [yen tee withthe decsinactin bt you ae whapy wih sepa we andlor YOU" provider took co ‘ake the decision, you also can contact un wotellea why you ae unkeooy your teat provider would like to dis callirg the Moi from the date of the dea! natfcation, AD-A168 or fr hearng rapaned TT loko rg yos wi expect the help you i help lo explass de infarnaton or provi ge We nay have this % ths denial decision with te physician reviewer, he or sho Hams) Depart at 1-800.6424168 fram 9.00 am to 500 em he ean do 40 by ea ne ante vst O- webu at ww Mtinaeatrarcam or all Member Seve 50-0750 oF 711, Represenatives are committed to ati will be available to assist you from ? tact Member Servioes fer help at no on rally, in English o in your primary famavon jesced w cena ober Inguages om obber ways It your gener oe, Union ou Nurse Advice Line open 24 haus seven dys a waok Registered muses vl help you understand wd menage your health and medical conciuans 3ee-275-8730 |-866-648.3537 (Bsparol) 1-86-735.2929 o¢ 717 (TTY) Sincerely, Thighs Kina Phir BD hulp Hans Pharm D Prosmacy Direstor ce MOC HENRY 1980 FOLARIS PKWY STE 200 COLUMBUS, C8 43240 Molina Healthcare of Ohio « P.O. Bex 349020 « Columbus, OF 43234.5020 MolinaHealtheare corn MO 435 onaSep 22 2814 14:28:28 ATAT/CVS Pharmacy -> Page 882 Date Member Subject. 9722/2014 Dental Letter Provide KEDAR DESHPAADE Mamba 1: aeRO Due sien — Dear Member member Bose for authorization of EXALGO ER BMG TAB dated OOF 92014 fo the above rember Based on the information provided by the request oF guidelines forthe above noted services) hy Provider, the established medical ‘€ nat becni met at this time Therefore this request has been dened W EXAL nadical resord documentation of a therapeute 5 deni + Pharniacy guidelines for EXALGO. lure on, contraindication 1a or intolerance to ONE ER TABLETS, Pl OF OXYMORPHONE ER In order to eon menting failure to formula W cost alternatives, OXY MO} {LOU don’t agree with hs astion, you, your provide, your hgal representative, fF someone you faye flowed io act on your behalf can ask tha we cae aur decisowmnion ‘This request is called an sl ask for an appeal within 90 devs of the mailing date of thir nonce Wen wrower within (5 calendar days ot vous request for en appeal Waa t2- 1891, sen in writing tthe address below or submited via the tema Appeals Coordinator Molina Healtheare of Ohio P.O Box 349020 Columbus, OH 43234-9020 Make site to include your name, member number, reasons for appesi a telephone number ren at teach 70% and any information you watt ttch auch teen or provider Iellers We also have told your provider ofthis action and wher hee 1e needs to do t0 Forth sppese gah you want you provider, a lawyer, or someone ee serene oe dea Beth You must tll us this in wnting. You have the nght fosubann wero comments, cuments, oF othet information related tothe appeal You asthe he ae access copies of spect crane et Your appeal, including information ceparding the oironee oe Specialty ofthe providers who feviewed your appeal,Sep 22 2814 14:29:88 ATRI/CVS Pharmacy -» Page 883 “Yo may chi «copy of the benefit provisions, treatment guidelines and reria used to render by eee On BY seni a reuse us atthe aes ented above ory contig by telephone * you or your provider believe that wating up to 15 calendar days to decide your appeal could Seriously risk your life or health, inluding your being abe o reach, kesp, oc gor bok oy your sarecrum [eretion, you er your provider should tell us this when asking for an ape ve ‘eres, we wll expedite of make a decision scone: (within thee working days) * TERS AIS BRIE teste, sop fo a while, or enda service we had already approved you to Taal see Gin peal the action You have the righ to keep ating the seve se aeoraced soul as make our dscivion om your appeal Ta keep geting the service you men see Ppeal eather within 15 working days of the mailing date of tis noice or the eifecive dae ofthe Te ns tppeal the action and keep geting the service, you may have to pay lor the ence {Eide Ohio Department ot Medicaid (ODM) deerdes that we ated corecty b behavior on your part cause of fradvlent * it you have questions or need additional assistanee, you may contact the Ohio Department of Medicaid Consumer Hotline online si Litp.hjouih gon or by phone at (809) 324-8680 or for hearing impaired TTY/Ohio Relay (800) 292-3572 or 711 * Cahtas have the right to ask for astae hearing. A hearing oe ftom the Ohio Deparment of raieattl (ODM) wil deide if we made he right decision. Ifyou want a sate hearing roa net ‘low the directions on the enclosed form within 99 days afer the mailing date ofthienones * (opunaree with the decision sition but you ae unhappy withthe steps we andor your prover ‘wok ta make the Weesion, you also can canaei us i el ws why you ate unheppy LY Seti provider would like to discus this denial decision with the physician reviewer, he or she $33 630 by calling the Wiohina Healthcare Pharmacy Department at |-804-642-4168, ot arya? 9° 25m to 5:00 p.m Monday through Friday withix seven days ftom the date ofthe dena notification gion have any questions, please vist our website at www MolinaHeattheare com or eall Member Reptss 1-800-642-4168 of for hearing impaized TTYiOhio Relay 1-800-750-0750 or 711 epitome are commited to reting you with especi and gating you te help you need A ‘epresenitve will beavaiuble te asist you fiom 7am. to7 pm, Monday through Fridey Teyou hay oy problems in read or understanding this information, please contact Member Services Ex ele atna cost» you We ean help wo explain the information ot provide ite mien ee orally, in ‘rash or yout mary language We may have this information printed inconmr anes languages or ater ways [F your vision andor hearing ae impr, special help can be provided in jedtlon, Gur Nurse Advice Lines open 24 hours, seven days a week Registered nurses wil help you undetstind and manage your health and medica) conditions 1.888.275.8750) 1-866-648.3537 (Espanol) 1-866-735-2929 or 711 TTY) Kintisisy Baylis Kage! Kimberly Brovles-Kpogli Pharm 1D. MBA, PMP. Pharmacy Direstor