State of Louisiana Division of Administrative Law @.O. Box 4189, Baton Rouge, £A 70821-4189 Phone (225) 342-0143 Fax 9.9823 ‘Located at 1020 Florida Street, Baton Rouge, LA. 70802 wunadmintow state laus JOHN BEL EDWARDS EMALIE A. BOYCE NOTICE OF FAIR HEARING January 26, 2022 Mr. Jeffrey Bodi Inthe Matter of Jeffrey Bodin $28 Beau Chene Drive DAL Docket # — 2022-0424-LDH Mandeville, LA 70471 Recipient ID # 5794038645696 Parish of Residence St, Tammany The hearing you asked for has been set as follows February 08, 2022 at :00 PM T YOU AND ALL OTHER PARTIES MUST EACH PHONE THE ADMINISTRATIVE LAW JUDGE AT THE ABOVE TIME AND DATE OF THE HEARING, USING THE TOLL FREE TELECONFERENCE, NUMBER AND INSI rIONS THAT ARE ATTACHED TO THIS NOTICE. Do not call the telephone nclosed calling instructions at any time or date other than that shown above for your hearing. It you have a representative or witnesses you want to testify at the phone hearing, they shoukd be at your location with you when you call in for your hearing. ‘The Administrative Law Judge will be in another location and will conduct the hearing by telephone. At the hearing, the Louisiana Department of Health (Department) will also appear by phone and pre A Summary of Evidence prepared by the Department explains the reasons for the Department's decision. If you or your witnesses have documents you want to use to support your ease, please immediately send the documents to the address below. or fax the documents to (225) 219-9823. Send your documents before the hearing. PLEASE STATE THE DAL DOCKET NUMBER ON ALL CORRESPONDENCE At the hearing, you may present oral and written evidence, and cross-examine any witnesses. ‘The hearing will be recorded and testimony will be taken under oath. If you wish to subpoena witnesses and/or documents, contact the LDH Deputy Clerk, so that subpoenas may be issued timely. final decision on the ease will be made on the record of evidence. You may represent yourself or use legal counsel, a relative, friend, or other spokesperson. If'an attorney will represent you, the attorney must enroll now by filing a written motion with the Division of Administrative Law. Eee el Providing Impartial Hearings for Government and Citi tn gual Opportumty Employer LRA summary ofthe evide is enclosed. C1 _ isnot enclosed, but will be forwarded to you before the hearing. (21 has been forwarded to you by the Louisiana Department of Health If you are unable 10 attend the hearing, you should contact this office immediately. He: rescheduled only upon showing of good cause, ce prepared by the Louisiana Department of Health ings are postponed or In compliance with the Americans with Disabilities Act, individuals neet language interpreter during this proceeding should call (25) 342-0443. days prior to the hearing. special accommodations, or a foreign ;o0n as possible, or at least three business DAL intends to send all future orders and correspondence in your case, including the Judges decision, to your e~ mail address. If we do not have your e-mail address and you would like us to communicate with you by e-mail, contact DAL at LDHProcessing @adminlaw.state.la.us and state that you want DAL to use that e-mail address to communicate with you in this case, Ifyou want to withdraw your appeal of the Department’s determination, please check the box below, sign, and mail or fax the signed document to the address indicated Docket No.: 2022-0424-LDH I withdraw my appeal of the Department’s determination, [If you cheek this box you must sign and date below; fax this to 225) 219-9823 or mail to address below.) Your Si Date: EMAIL documents pHi Processing @adminlaw.state bus ATTN: LDH Section Deputy Clerk FAX documents to P.O. Box 4189 LDH Section Deputy Clerk Baton Rouge, LA 70821 (225) 219-9823 ce: Ms, Peggy MeCurry, Aetna Better Health of Louisiana Stella Joseph, Aetna Better Health of Louisiana Ms. Connie Lewis, Healthy Louisiana IRDIVISION OF ADMINISTRATIVE LAW. Telephone Conference Instructions Read and follow the instructions below carefully. This information is only for Docket # 2022-0424-LDH . Do not use the dial-in number and access code for any other case. After the telephone hearing, the dial-in number and access code are no longer useful. If you have any problems using the dial-in number and access code please eall (225) 342-6291 or (225) 342-0443. 1. Dial 1-877-873-8018. 2. Listen for this Recording: “Welcome 10 AT&T's teleconference service. Please enter your access code followed by the pound sign. Do This: Enter 3151576 then press the # key on the phone, 3. Listen for this Recording: “To join the conference as the host press star otherwise press pound. Do This: Press the # key. 4. The next recording that you will hear depends on whether the Judge has joined the conference yet © Ifthe Judge has NOT joined the conference call, you will hear: The host has not yet arrived, Please stand-by © You should wait for the Judge to join the call, When the Judge joins, you will hear: There are (__) participants on the call, including you. You are now being joined to your conference. Ai the tone, please speak your name.” Do This: Say your name. [You MUST say your name after the tone.] © Ifthe Judge HAS joined the conference call, you will heai ‘At the tone, please speak your name. You are joining your conference ax a participant.” Do This: Say your name. [You MUST say your name after the tone.) 5. [fat any time you think you cannot be heard by the judge, hang up and follow the same instructions to call hack 6. Atthe end of the hearing, the Judge will let you know when you can hang up. [E Phone Conference Tips T, The "host" isthe Administrative Taw Tndge 2. ‘The Appellant, the Department, and any witnesses are the “participants.” 3. Speak naturally and say your name each time before you begin speaking 41. Pause for thers to speak. DO NOT INTERRUPT OTHERS. 5, Spell out unusual terms, names, and numbers. 6. Do not rustle pages or make distracting noises; everyone can ea i 7. Avoid putting your phone on hold. Phone systems with music-on-hold will disrupt the teleconference servicePRIVACY AND FIDENTIALITY WARNING ‘The attached document contains Protected Health information (PHI), Individually Identifiak>le Health Information (WH!), and other information which is protected by law. The document is only fear the use of the intended recipient. Use of this information by anyone other than the intended recipient may ‘result in legal action. if you are not the intended recipient, be on notice that any review, discll osure/re- Gisclosure, copying, storing, distributing, or the taking of action in reliance on the contemts of the document and any attachments, is strictly prohibited. if you are not the intended recipie nt and/or have received the document in error, please (1) immediately notify the sender by callings (225) 342-0443 or (225) 342-6291 that this document and any attachments have been inadvertently transmitted to you, and (2) return the document and any attachments to: Division of Administrative Law LDH Section P.O. Box 4189 Baton Rouge, LA. 70821-4189ML. SUMMARY OF EVIDENCE IDENTIFYING INFORMATION Jeffrey Bodin Docket # 2022-0424-LDH ACTION CLAIMANT IS APPEALING Jeffrey Bodin is appealing the denial for the medication Amphetamine Dextroamphetamine. EXPLANATION OF ACTION ‘On October 13, 2021. the health plan received a prior authorization request for Amphetamine-Dextroamphetamine 30 milligram tablets to be taken three times a day (Exhibit A), After review of the prior authorization information (Exhibit A), it was determined the prior authorization for Jeffrey Bodin’s medication was denied for requested dose above the Food and Drug Administration's maximum of 30 milligram tablets, two tablets a day for narcolepsy diagnosis. According to the criteria used, Louisiana Medicaid Stimulants and Related Agents and Quantity Level guideline, this drug is not approved by the Food and Drug Administration at the requested dose to treat condition. The medical literature does not find it safe and effective (Exhibit B). On October 14, 2021, the Notice of Action determination letter (Exhil to the member and faxed to the provider. C) was mailed On December 0. 4 verbal appeal request and clinical study (Exhibit D) were received from Jeffrey Bodin for reconsideration of prior authorization denial for Amphetamine-Dextroamphetamine medication On December 30, 2021, the Medical Director Gary Rhule reviewed the appeal request (Exhibit D) and medical records and made the following determination: ‘The health plan will not approve the request. The health plan can cover 30 milligram tablets, 2 tablets a day. Your doctor ordered 30 milligram tablets, 3 tablets a day. You have narcolepsy (a condition causing extreme daytime sleepiness). This drug is not approved by the Food and Drug Administration at the requested dose to treat your condition. The medical literature does not find it safe and effective. A second doctor Board Certified in Neurology completed a same or similar specialist review (ExhibitL On December 30, 2021, the appeal decision letter (Exhibit E) was mailed to the member. RELATED DOCUMENT! Exhibit A: Prior Authorization Request ~ 2 pages Exhibit B: Guideline - 7 pages Exhibit C: Notice of Action — 7 pages Exhibit D: Appeal Request — 45 pages Exhibit E: Appeal Decision Letter — 9 pages Exhibit F: Same or Similar specialist Review- 3 pagesClinical Authorization System Page 1 of 2 —— 5 = Pasuna hitps://cas.caremark.com/CASWeb/showPAHistory.action?memberFirstName=8member... 12/10/2021Clinical Authorization System Page 2 of 2 [renstes Reason escnpion Prescribed Org fa rresoero Jeanie fon [ere nate esotaan Nome [Seana Resour Tote [congure wares eee Waco https://cas.caremark.com/CASWeb/showPAHistory.action’memberFirstName=S&member... 12/10/2021Louisiana Medicaid Stimulants and Related Agents The Louisiana Uniform Prescription Drug Prior Authorization Form should be utilized to request: * Clinical authorization for all preferred and non-preferred agents for recipients younger than 7 years of age; OR * Prior authorization for non-preferred agents for recipients 7 years of age and older. Additional Point-of-Sale edits may apply. These agents may have Black Box Warnings and/or may be subject to Risk Evaluation and Mitigation ‘Strategy (REMS) under FDA safety regulations. Please refer to individual prescribing information for details. Initial and Reauthorization Approval Criteria for ALL Stimulants and Related Agents (both preferred and non-preferred) for Children under 7 years of Age [except armodafinil (Nuvigil®), modat (Provigil®), pitolisant (Wakix®) or solriamfetol (Sunosi®)]: * For dexmethylphenidate ER capsules (generic for Focalin XRW®) - there has been a treatment failure or intolerable side effect with or contraindication to brand Focalin XR®; OR * There is no preferred alternative that is the exact same chemical entity, formulation, strength, ete.; AND + Previous use of a preferred product - ONE of the following is required: © The child has had treatment failure with at least one preferred product; OR © The child has had an intolerable side effect to at least one preferred product; OR (© The child has documented contraindication(s) to the preferred products that are appropriate for the condition being treated; OR © There is no preferred product that is appropriate to use for the condition being treated; AND ‘The child has a diagnosis approved for the medication requested (see POS Edits); AND ONE of the following (due to this diagnosis) is rue and is stated on the request: © Child has had a trial of behavioral therapy and has ongoing impairing and/or dangerous symptoms; OR (© Child has started behavioral therapy but has extremely impairing and/or potentially dangerous symptoms; OR (© Child has been referred to behavioral treatment but has extremely impairing and/or potentially dangerous symptoms that warrant treatment before therapy has had a chance to have an effect (with plan to follow up); OR © There are no known behavioral therapy resources available to this child, who has extremely impairing and/or potentially dangerous symptoms; OR © ALL of the following: The child is 6 years of age; AND. + The diagnosis for the requested medication is attention deficit hyperactivity disorder (ADHD); AND By submitting this request, the provider attests that behavioral treatment has been prescribed in addition to the requested medication; AND By submitting the authorization request, the prescriber attests to the following:© Clinical monitoring parameters recommended in prescribing information are completed at baseline, every six months, and with dosage changes; AND ©. The prescribing information for the requested medication has been thoroughly reviewed, including any Black Box Warming, Risk Evaluation and Mitigation Strategy (REMS), contraindications, minimum age requirements, recommended dosing, and prior treatment requirements; AND © All laboratory testing and clinical monitoring recommended in the prescribing information have been completed as of the date of the request and will be repeated as recommended: AND (© The recipient has no concomitant drug therapies or disease states that limit the use of the requested medication and will not receive the requested medication with any other medication that is contraindicated or not recommended per FDA labeling: OR ‘© For dexmethylphenidate ER capsules (generic for Focalin XR®) - there has been treatment failure or intolerable side effect with or contraindication to brand Focalin XR®; OR ‘¢ There is no preferred alternative that is the exact same chemical entity, formulation, strength, etc.; AND ‘© The child has a diagnosis approved for the medication requested (see POS Edits); AND ‘+ The prescriber states on the request that the recipient is established on the requested medication with positive clinical outcomes; AND + By submitting the authorization reques the prescriber attests to the following: © Clinical monitoring parameters recommended in prescribing information are completed at baseline, every six months, and with dosage changes; AND © The prescribing information for the requested medication has been thoroughly reviewed, including any Black Box Waring, Risk Evaluation and Mitigation Strategy (REMS), contraindications, minimum age requirements, recommended dosing, and prior treatment requirements; AND © All laboratory testing and clinical monitoring recommended in the prescribing information have been completed as of the date of the request and will be repeated as recommended: AND (© The recipient has no concomitant drug therapies or disease states that limit the use of the requested medication and will not receive the requested medication with any ‘other medication that is contraindicated or not recommended per FDA labeling Duration of Initial and Reauthorization Approval for ALL Stimulants and Related Agents (both preferred and non-preferred) for Children under 7 years of Age [except armodafinil (Nuvigil®), modafinil (Provigil®), pitolisant (Wakix®) or solriamfetol (Sunosi®)|: 12 months or up to the reci 7 birthday, whichever is less Approval Criteria for Non-Preferred Stimulants and Related Agents [except armodafinil (Nuvigil®), modafinil (Provigil®), pitolisant (Wakix®) or solriamfetol (Sunosi®)] for Recipients 7 years of Age and + For dexmethylphenidate ER capsules (generic for Focalin XR®) - there has been treatment failure or intolerable side effect with or contraindication to brand Focalin XR®; OR # There is no preferred alternative that is the exact same chemical entity, formulation, strength, etc.; AND * Previous use of a preferred product - ONE of the following is required: 2© The recipient has had crearment failure with at least one preferred product; OR © The recipient has had an inrolerable side effect to at least one preferred product; OR © The recipient has documented contraindication(s) to the preferred products that are appropriate for the condition being treated; OR © There is no preferred product that is appropriate to use for the condition being treated; OR © The prescriber states on the request that the recipient is established on the requested medication with positive clinical outcomes; AND ‘+ The recipient has a diagnosis approved for the medication requested (see POS Edits); AND. ‘+ By submitting the authorization request, the prescriber attests to the following: ‘© Clinical monitoring parameters recommended in prescribing information are completed at baseline, every six months, and with dosage changes; AND © The prescribing information for the requested medication has been thoroughly reviewed, including any Black Box Waring, Risk Evaluation and Mitigation Strategy (REMS), contraindications, minimum age requirements, recommended dosing, and prior treatment requirements; AND © All laboratory testing and clinical monitoring recommended in the prescribing information have been completed as of the date of the request and will be repeated as recommended; AND © The recipient has no concomitant drug therapies or disease states that limit the use of the requested medication and will not receive the requested medication with any other medication that is contraindicated or not recommended per FDA labeling. Reauthorization Criteria for Non-Preferred Stimulants and Related Agents [except armodafinil (Nuvigil®), modafinil (Provigil®), pitolisant (Wakix®) or solriamfetol (Sunosi®)] for Recipients 7 Years of Age and Older ‘© Recipient continues to meet initial approval criteria; AND ‘+ The prescriber states on the request that the recipient is established on the medication with evidence of a positive response to therapy. Duration of Initial and Reauthorization Approval for Non-Preferred Stimulants and Related Agents j1@), modafinil (Provigil®), pitolisant (Wakix®) or solriamfetol (Sunosi®)] for Recipients 7 Years of Age and Older: 12 months Approval Criteria for Non-Preferred Armodafinil (Nuvigil®), Modafinil (Provigil®), Pitolisant (Wakix®) and Solriamfetol (Sunosi®) + On the date of the request, the recipient age is: © IT years of age or older for armodafinil or modafinil; OR © 18 years of age or older for pitolisant or solriamfetol; AND ‘© There is no preferred alternative that is the exact same chemical entity, formulation, strength, etc.; AND ‘© Previous use of a preferred product - ONE of the following is required: © The recipient has had treatment failure with at least one preferred product; OR © The recipient has had an intolerable side effect to at least one preferred product; OR © The recipient has documented contraindication(s) to the preferred products that are appropriate for the condition being treated; OR 3© There is no preferred product that is appropriate to use for the condition being treated; OR © The prescriber states on the request that the recipient is established on the requested medication with positive clinical outcomes; AND ‘© The recipient has a diagnosis approved for the medication requested (see POS Edits); AND ‘© By submitting the authorization request, the prescriber attests to the following: © Clinical monitoring parameters recommended in prescribing information are completed at baseline, every six months, and with dosage changes; AND ‘© The prescribing information for the requested medication has been thoroughly reviewed, including any Black Box Warning, Risk Evaluation and Mitigation Strategy (REMS), contraindications, minimum age requirements, recommended dosing, and prior treatment requirements; AND © All laboratory testing and clinical monitoring recommended in the prescribing information have been completed as of the date of the request and will be repeated as recommended; AND The recipient has no concomitant drug therapies or disease states that limit the use of the requested medication and will not receive the requested medication with any other medication that is contraindicated or not recommended per FDA labeling ion Criteria for Non-Preferred Armodafinil (Nuvigil®), Modafinil (Provi .®) and Solriamfetol (Sunosi®) ), Pitolisant ‘+ Recipient continues to meet initial approval criteria; AND + The prescriber states on the request that the recipient is established on the medication with evidence of a positive response to therapy. Duration of Initial and Reauthorization Approval for Non-Preferred Armodafinil (Nuvigil®), Modafinil (Provigil®), Pitolisant (Wakix®) and Solriamfetol (Sunosi®): 3 months References Clinical Pharmacology {database online]. Tampa, FL: Gold Standard. Inc.: hutps://www.clinicalkey.com/pharmacology DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10¢ New York, NY: McGraw-Hill; https://accesspharmacy.mhmedieal.com,book.aspx?bookid= 1861 Gleason, M., Egger, H., Emslie, G., Greenhill, L., Kowatch, R., Lieberman, A., Luby, J., Owens, J., Scahill, L., Scheeringa, M., Stafford, B., Wise, B. and Zeanah, C. (2007). Psychopharmacological Treatment for Very Young Children: Contexts and Guidelines. Journal of the American Academy of Child & Adolescent Psychiatry, 46(12), pp.1532-1572Revision / Date Implementation Date Single PDL Implemented May 2019 ‘Added specific wording for use of Focalin XRW and ProCentra® / November 2019 | January 2020 Removed POS information, added Wakix®. formatting changes, updated references / July 2020 sabia Modified to apply new age requirement for behavioral health clinical authorization, | ya s.a2, 9994 updated references / September 2020 Removed preferred wording for ProCentra®, formatting changes, updated references / November 2020 See Added wording for Sunosif, formatting changes / September 2021 October 2021aetna AETNA BETTER HEALTH® Coverage Policy/Guideline Name: Quantity Level Limit Guideline Page: Lof2 Effective Date: 6/1/2019 Last Review Date: 02/2019 california OFlorida Dikentucky Appliesto: louisiana OMaryland michigan OPennsylvania Virginia OTexas Intent: The intent of this policy/guideline is to provide information to the prescribing practitioner outlining the coverage criteria for Quantity Level Limit requests under the member's prescription drug benefit Description: Requests for Quantity Level Limits that do not have specific Prior Authorization Guidelines. Policy/Guideline: Prescription requests that exceed established Quantity Level Limits will require prior authorization. Drugs that are subject to additional utilization management requirements (for example, non- formulary, clinical prior authorization, and step therapy) must meet the clinical criteria and medical necessity for approval in addition to any established Quantity Level Limits. Approval of Quantity Level Limits exceptions will be considered after the medication specific prior authorization guidelines and medical necessity have been reviewed. Authorization Criteria For Quantity Limit Exceptions: ‘= Quantities that Exceed Food and Drug Administration (FDA) Maximum Dose: ‘© Member is tolerating the medication with no side effects, but had an inadequate response at lower dose, and the inadequate response is not due to medication non- adherenceaetna AETNA BETTER HEALTH® Coverage Policy/Guideline Name Quantity Level Limit Guideline Page: 2of2 Effective Date: 6/1/2019 Last Review Date: 02/2019 Ticalifornia OFlorida Ckentucky Applies to: Etouisiana Maryland Omichigan DPennsylvania virginia Texas ‘© Request meets one of the following © Requested dose is included in drug compendia or evidence-based practice guidelines for the same indication = Apublished randomized, double blind, controlled trial, demonstrating safety and efficacy of requested dose is submitted with request ical ‘© Quantities that do not Exceed Food and Drug Administration (FDA) Maximum Dose (Dose Optimization): ‘© Request meets one of the following: ‘There was an inadequate response or intolerable side effect to optimized dose There is a manufacturer shortage on the higher strengths + Member is unable to swallow tablet/capsule due to size, and cannot be crushed ‘+ Effect of medication is wearing off between doses + Member cannot tolerate entire dose in one administration + Quantities for Medications that do not have Established Food and Drug Administration (FDA) Maximum Dose: © Members tolerating the medication with no side effects, but had an inadequate response at lower dose, and the inadequate response is not due to medication non-adherence © Requested dose is considered medically necessary Approval Duration: Prior Authorization | Dur Approval ‘Quantity Restrictions | Additional Requirements Initial One year Renewal One year Box Warning: NIA REMS: N/A References: N/AAetna Better Health of Louisiana 2400 Veterans Memorial Blvd Kenner LA 70062 JEFFREY BODIN 528 BEAU CHENE DR MANDEVILLE LA 704712400 Veterans Memorial Blvd, Suite 200 on ee vaetna AETNA BETTER HEALTH® OF LOUISIANA Notice of Denial 10/14/2021 JEFFREY BODIN 528 BEAU CHENE DR MANDEVILLE, LA 70471 Member ID: ****#####5696 Requesting Provider: KEVIN MCLAUGHLIN, Date Request Received: 10/13/2021 5:00:21 PM Requested Service: AMPHETAMINE/DEXTROAMPHETAMINE 30MG TAB Requested Dates of Service: 10/14/2021 Authorization Number: 21-055261762 Dear JEFFREY BODIN: We are writing to tell you that your request for AMPHETAMINE/DEXTROAMPHETAMINE 30MG_ TAB for dates of service 10/14/2021 is denied and Aetna Better Health of Louisiana will not pay for the care. To find out why we won't pay, keep reading. If you think we made a mistake, you may ask for an appeal Hf you have questions, call Aetna Better Health of Louisiana at 1-855-242-0802. Hearing impaired TTY 7-1-1. This call is free. Your doctor also got a copy of this letter, so you should also talk to your doctor. ‘Why won't Aetna Better Health of Louisiana pay for AMPHETAMINE/DEXTROAMPHETAMINE 30MG TAB for dates of service 10/14/2021? Based on a review of our Quantity Level guideline. Your doctor asked Aetna Better Health of Louisiana to cover the drug, amphetamine-dextroamphetamine. The health plan will not approve the request. The health plan can cover 30 milligram tablets, 2 tablets a day. Your doctor ordered 30 milligram tablets, 3 tablets a day. You have narcolepsy (a condition causing extreme daytime sleepiness). This drug is not approved by the Food and Drug Administration at the requested dose to treat your condition. The medical literature does not find it safe andeffective. The preferred drug lst is on the health plan formulary. You can find the formulary on the health plan website. You can call the health plan to help you. The Member Services telephone number is on your health plan identification card. A paper copy of the formulary can be sent if needed. Decisions about the care that you will have are between you and your doctor. Please talk to your doctor about your treatment options. To access the criteria online go to: http://Idh.la.gov/assets/Healthyla/Pharmacy/PDL.pdf. To get a free copy of the guidelines used to make this decision, you can also email: PharmacyPriorAuthorization@aetna.com. Because of all the reasons stated, Aetna Better Health of Louisiana does not think the care is medically necessary. To get a free copy of the guidelines used to make this decision, call 1-855-242-0802. Hearing impaired TTY 7-1-1. You or someone legally authorized to do so, can ask for a free copy of the criteria, guidelines or any other information we used to make this decision by calling 1-855-242-0802. Do you have questions? Call us at 1-855-242-0802. You may also want to talk to your doctor. Does your doctor want to talk to someone about this decision? Your doctor can call Aetna Better Health of Louisiana at 1-855-242-0802. For medical necessity denials, the treating doctor may request a Peer to Peer Review. To request a Peer to Peer review, please call 1-855-242-0802, Press *, Say “Authorization’, Say “Submit One”, Say “Pharmacy”. A Prior Authorization Representative will answer and schedule a “Peer to Peer Review.” What can you do if you think Aetna Better Health of Louisiana made a mistake? If you think we made a mistake, you may ask for an appeal. if you want to request an appeal, you must do so within 60 calendar days from date of this notice. You can choose to file an appeal yourself, or you can choose another person, including an attorney or your doctor, to act ‘on your behalf. if your dactor or comeane else appeals for you, you must give them written permission. You have the right to ask for a State Fair Hearing. You may ask for this after the appeal process with Aetna Better Health of Louisiana has ended. We will tell you how to ask for a State Fair Hearing when you get the final appeal decision. How do you ask for an appeal? There are three ways you can ask for an appeal: © Call Aetna Better Health at 1-855-242-0802 ‘* Mail the Request for Appeal form to:Aetna Better Health of Louisiana Appeals & Grievances Department PO Box 81139 ‘5801 Postal Rd Cleveland, OH 44181 © Fax the request for appeal to 1-860-607-7657, How long does it take to make a decision about my appeal? We will make a decision within 30 calendar days of getting your appeal. What if you need a fast decision? If your condition is considered urgent, we may be able to make a decision about your appeal much sooner. You may need a fast decision if, by not getting the requested services, one of the following is likely to happen: '* You will be at risk of serious health problems, or you may die; '* You will have serious problems with your heart, lungs, or other body parts; or © You will need to go into a hospital Your doctor must agree that you have an urgent need. Ifa fast decision is needed, we will review your appeal and send a written decision within 72 hours of our receipt of your appeal How do | continue to receive this service during the appeal? If you are already receiving this service, you have the right to continue benefits while an appeal is in process. You must ask for this within 10 calendar days from the date of this notice by calling Aetna Better Health of Louisiana at 1-855-242-0802. If the appeal decision or state fair hearing agrees with the denial, you may have to pay the cost of the service you received. Do you need help with this letter? Call Aetna Better Health at 1-855-242-0802. If you need help in another language, call 1-855-242-0802 (toll-free). Para obtener ayuda para traducir 0 entender esta informacion, sirvase llamar al 1-855-242-0802 0 TDD/TTY 7-1-1, entre 8 a.m. y 5 p.m. Dé dude giup phién dich hoc hiéu phan nay, xin goi s6 1-855-242-0802 hoc TDD/TTY 7aa Sincerely, Prior Authorization Department Aetna Better Health of Louisianace: KEVIN MCLAUGHLIN 106-MA102LAA1 12162019vaetna AETNA BETTER HEALTH’ OF LOUISIANA Nondiscrimination Notice Aetna complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Aetna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. 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If you need help filing a grievance, our Civil Rights, Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal. hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room SOSF, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD) Complaint forms are available athttp://www-hhs.gov/ocr/office/file/index. html Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, and its affiliates LA-16-09-02Multi-language Interpreter Services ENGLISH: ATTENTION: If you speak English, language assistance services, free of charge, are available to you Call the number on the back of your ID card or 1-800-385-4104 (TTY: 713). SPANISH: ATENCION: Si habla espafiol, tiene a su disposicidn servicios gratuitos de asistencia linguistica. lame al numero que aparece en el reverso de su tarjeta de identificacién o al 1-800-385-4104 (TTY: 711). FRENCH: ATTENTION: si vous parlez francais, des services d’aide linguistique vous sont proposés gratuitement, Appelez le numéro indiqué au verso de votre carte d’identité ou le 1-800-385-4104 (ATS: 711). VIETNAMESE: CHU Y: néu ban néi ting viet, ¢6 cdc dich vu hé tre ngén ngir mién phi dinh cho ban. Hay goi sé c6 6 mat sau thé id cisa ban hoc 1-800-385-4104 (TTY: 711} CHINESE: (Ei: MULLS (HY ARP. BST Ee HE A ak RBIS, CAL Fie 1-800-385-4104 (TTY: 711). AS ID PE ad ARABIC: yn all AbD gle Seed hal Al ABA, gD Boel CaaS Ad yy pl ll asa CS YA yale (711 25.2) 5 all) 1-800-385-4104 Je Anas. title ‘TAGALOG: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika, Tumawag sa numero na nasa likod ng iyong ID card 0 sa 1-800-385-4104 (TTY: 711] KOREAN: #91: SHR OS ASAE BS, Ai AA MAS Pes Sas + ASUCL Hat QhS WS SL} 1-800-385-4104 (TY: 711) MLE AHS} FLAS SlctoH PORTUGUESE: ATENCAO: Se fala portugués, encontram-se disponiveis servicos linquisticos, gratis. Ligue para © nimero que se encontra na parte de tras do seu carto de identifica¢o ou 1-800-385-4104 (TTY: 711) LAOTIAN: Guan: tadrwiaudaurarars, nuddnweoededwunas, toudern, auudiovtivin. Youn uidgcinupigdouetndiozequiny Q 1-800-385-4104 (TTY: 711) JAPANESE: (06 WIA: HAS & Bails 4 B Hild REE IDA FRU O Wiad iS. 4 fo 14 1-800-385-4104 (TTY: 711) 4 CS URDU: - Shy IS LOLS eS SH Gler a OU) 9 us dy CU all Saws oe S$ Bil y (TY: 711) 800-385-4104 Ve ai Sot aoe SS SL GERMAN: ACHTUNG: Wenn Sie deutschen sprechen, konnen Sie unseren kostenlosen Sprachservice nutzen. Rufen Sie die Nummer auf der Riickseite Ihrer !D-Karte oder 1-800-385-8104 (TTY: 711) an, PERSIAN: «als sche Ais yond ily} SUS ashy tN pe TN pen a ge Cte pe aj SI 1284 sols (TTY: 711) 1-800-385-4104 » ass RUSSIAN: BHIMAHME: ecnn abi rosopuTe Ha pyccKOM sabike, aM MOryT NpenocTaBHTe GecraaTHble ycAyrH nepesona. Nossounte no Homepy, ykaaHHOMy Ha O6paTHo! cropone sawed uaeHTHgMKaKOHHOH KapTOMKN, nn no Homepy 1-800-385-4104 (TTY: 711) THAI diomaaets: hhanman aT inn Arutanso LeLANTstUMdawnTE ANS ‘Tnsfiamamanaaatiardnundatins 10 vasan. wavsruian 1-800-385-4104 (TTY: 711) \A-16-09-02‘Appeal Request ~ Member Call Note 12/03/2021 (256-430pm) - Outbound call to member @ 985-520-4713 regarding pharmacy issue of ‘getting medications, Spoke to member who confirmed he has been having issues getting the medication Amphetamine-Dextroamphetamine and has been paying out of pocket to get the needed medication. ‘Member stated he has been able to get some of the cost covered but has paid for some as well. This is how he was able to get his medication on 11/12/2021 but cannot afford to keep doing this he stated, Member stated he has cancer and narcolepsy which is why he is ordered the dosage of medication he is ‘on. Member stated he has been working with his doctor to get to a therapeutic dose because of his high seizure risk, Member stated he is on disability as well because he is not allowed to drive due to his, seizure history and risk. Member stated he cannot go to the pharmacy because of this to deal with the issues regarding his medications. Member stated he was able to get this medication back in 2018 and there have been issues recently and he has spoken to multiple people who cannot seem to figure out ‘what is going on and fix it. Member stated he's was also not able to get his Celebrex medication due to needing to try alternatives. Member stated he is not able to try the preferred medications due to his cancer. HP reviewed CAS PA history and denials with member that show multiple PA submission from Dr. Mclaughlin with a few P2P's dating back to 2018. No appeals have been submitted for Amphetamine-Dextroamphetamine HP advised and member asked if he can file an appeal now. HP notified member that he can file an appeal now and HP will contact Dr. Mclaughlin’s office to obtain medical records to support appeal. Member stated he also has @ medical study he would like to submit for appeal as well. HP provided fax # for A&G LA.Kevin E. McLaughlin, M.D., D.A.B.S. 350 Lakeview Court, Suite A Covington, LA 70433 FAXED Phone (985) 845-2677 Se cey Fax: (985) 867-5498 is — FAX TRANSMITTAL [ DATE: TO FROM company: Cheb Cppasts Kevin Mclaughlin, M.D/ Assistant Regina S. ATTENTIO! Ashley 350 Lakeview Court, Ste A i Covington, LA 70433 | Phone 985-845-2677 (ext 208) FAX numer: X(Q) 004 - VWOST Fax No. 985-867-5498 COMMENTS ‘Bc pts Bt J Appeat for Wrote cairn No. of Pages Transmitted (INCLUDING TRANSMITTAL FORM) “The documents accompanying this telecopy transmission contain confidential information belonging to the sender that i legally privileged. This information is intended only for the use of the individual or eatity named above. The authorized recipient of this information is prohibited {om disclosing this information to any other party and is eequired to destroy the inforeution after its stated need has been fulfilled, unless otherwise required by state lawlf You are not the | intended recipient, you are hereby notified disclosure, copying, distribution, or action ‘aken in veliance on the content of these documents i strictly prohibited. If you have received this ‘elecopy in error, please notify the sender immediately to arrange for return on these documents. ez/te vd ecrsiseses © aziz8 Tz0z/zz/2T2021/12/17 14:39:48 1 #1 Prior Authorization Needed ss conn 2 MANDEVILLE, LA 704713317 Tel: 985-674-2551 Fax: 985-674-5304 ‘Dae; 12/17/2021 ‘Time: 2:39 PM Preserve foraion ° Pryor KEVIN MCLAUGHLIN Prone: 965.845.2677 Aabess’ — SSOLAKEVIEWCT for, sensor stoe SOuINGTON. LA Tosoa7s22 pens: suoeeses? Paioat tomato: : r Paten JEFFREY BOON Sirh Cute: 08221967 agrss: — SOBBEAUCHENE OA Mos Rese BRE MLLE CA 700711777 Crone, 966.272.4969 Prescription Information: = ic xNumber, 2501423-05382 fiuquined PU Tie: 12172001 025104 ‘Drug: D-AMPHETAMINE SALT COMBO 30MG- Qty: 90 Tas Las pall 2172001 Gener For: RODEAALL 206 TABLETS Se TOKE Yaa BY MOUTH THREE TIVES Daur iceman: Plan does not cover this medication. Please call plan at (855) 9642970 to iniate prior authorization or callax pharmacy to ‘change medication. Patient ID # is 8794038665608, inesioraarca wih aie epUGto7e, a prec wi bw wheihed uiewe oe ise nacaieg Coiecorse as Wotan :zra Medicny Necessary Please fax beck to Walgreens at: (985-674-5334 6z/ze ove sepsiseses oz:ze 1902/22/21Bodin, Jeffrey T (MRN 0744652) DOB: 05/22/1997 Encounter Date: 08/05/2016 — icf Houston, TX 77030 Phone: 713-792-2352 Multiple Sleep Latency Test Report | PATIENT PROFILE Patient Name: Bodin, Medical Record Number: 744652 Age: 19 (years) ‘Sex: Male Height: 168 cm Weight: 50.0 Kg BMI: 17.7 kglm2 ‘Study Date: 6/5/2016 Referring Physician: Dave Balachandran M.D.. MO. Epworth Sleepiness Score (ESS): 14.0 il DIAGNOSIS Hypersomnia 347.00 Narcolepsy, Unspecified Wl, PROCEDURE ‘The patient underwent a MSLT (multiple sleep latency test) according to the guidelines ‘established by the American Academy of Sleep Medicine’. The patient was allowed to nap starting at two hours post awakening from the baseline study and subsequently at 2 hour intervals. Ounng the baseline polysomnogram the sleep efficiency was 77/5%. There was no ‘evidence of clinically significant sleep disordered breathing, noctumal hypoxemia or movement disorders. The MSLT immediately followed the baseline study. ‘A total of four naps were performed. The patient slept during four of the four naps. The mean sleep latency (MSLT score) was 5.8 minutes. There were four sleep onset REM periods (SOREM) noted. ‘The diagnosis of narcolepsy requires 2 SOREMs, and an MSLT score of less than 8 minutes. (mean sleep latency). An MSLT score of less than 10 minutes with less than 2 SOREMS can bbe seen in idiopathic (CNS) hypersomnia, upper airway resistance syndrome, penodic limb movement disorder and sleep apnes. IV. CONCLUSION ‘The clinical history is suggestive of hypersomnia, and the MSLT is consistent with narcolepsy. Printed by Vivian C Esquivel, RN at 9/1/16 4:12 PM Page 1 of2 6z/eo Vd aerSL98s86 © ZZ TZZ/LZ/ZTPatient Name: Bodin, Jeffery Center ZZ ‘Ochsner Health System Le 4 atin” Sitep Sly HZ Tel: $04 842.4910 MSLT REPORT Clinic #: 2692229 Date of Study: 2/2/2015 Pationt Name: Bodin, Jeffery Hospital #: | 83000256150 Sex: Male Bead Date: DROS Doe: BOOST, Cine BS ge: a7 Referring Physician: | Ludmila Lyaenko, MO ‘Height: S700 ‘Referring Physician # [2478 a Weight: 7070 be ‘Stoop Specialist: | L Lysanko, MD em 788 Step Speciailet# [2478 iypopiea ruler | AASMIR ‘Scaring Tech: ABeciel RPSCT Total AE: [103 Recording Tech] Leanett Sandifer, ART Lowest 02 sat, | 01.0% Recording Location: | Ochsner Baptist ‘Sleep architecture: This is a baseline polysomnogram. At light's out, the patient fell asieep in 3.5 ‘minutes and sleot for 94.4% of the time. Total sleep time (TST) was 401.6 minutes. 5.4% of TST was in ‘Stage N1 sleep, 24.6% TST in slow wave sleep, and 27.2% TST in REM sleep. The REM iatency was 69.0 minutes. Sleep archlecture was mildly disrupted die to undertying sleep apnea, piratory: Mild snoring was present. There was mild, yet significant OSA (obstructive sleep apnea) ‘based on AHI (apnea hypopnes index) citeria. The overall AHI was 10.3 wih an oxygen nadir of 81.0% ‘The supine AH was 6.9 and the REM AHI was 30.4. The patient did not qualify for a spit night study due an inaufficient number of evants in the first hatf of tne study. Motor movement / Parasomnia: There were no significant limb movements of sleep noted. The total lim movernent index was 0.0 (0.0with arousal). Cardi ‘ardiae rhythm monitoring reveaied a normal sinus rhythm .. Pationt perception: On a post-sleep study questionnaire, the patient indicated thal slaep was “worse” in the lab than compared to home. MSLT: Nex day, for the MSLT 4 naps were recorded al 2 hour intervals, for approximately 20 minutes duration each, starting 2t a lights out time of 7:35 AM AM for Nap 1. She fell asleep on 4/4 naps and developed sleep onset REM periods (GOREMPs) on'fi4 ough 4. were 3:30 min, 1:00 min, 0:30 min, 2:00 min, respectively. The 4 nap-mean sleep latency was naps. The sleep ansat latency for Naps 1 jeverily diminished at 1.5 minutes. The patient fot thet she fell aioap on naps 1-4. Unne drug sereen ‘on the morning of the MSLT was negative, IMPRESSION: 1. Severily diminished steep onset latency of 1.6 minutes was noted on MSLT with 4/4 SORE! (sleep onset REM periods). This is suggestive of narcolepsy in appropriate clinical context 2, Mild, yet significant OSA (327.23) based on AHI eriteca RECOMMENDATION: 1. Clinieat correlation is suggested. 62 /re Ova Ludmila Se Lysenko, MD Saee—et sersisese6 © azze Tee /2z/2T6z/s0 Ochsner Health System Patient Name: Bodin, Jeffery MULTIPLE SLEEP LATENCY TEST: Analysis Start Tne: 73728 AM 9:20:58 AM Sloop Center Tel: 504 842-4910 PSG/MSLT REPO Clinic #: 2592229 Date of Study: 2722015 113328 AM 10:28PM NA Analysis End Time: 7:58:58 AM 9:45:SBAM 11:48:58 AM 1:57:28 PM NA, Time in Bed” 18:30 16:00 19:30 17:90 NA Total Sleep Time" 14:30 15:00 14:30 14:30 NA ‘Sleep Onset 03:30 01:00 00.30 2:00 A REM Latency’: 03:30 03.00 03:00 03:30 WA “Time formats are in mines. Now: report will ratuen dataultme = 20 min. for Sloop Onset ifna sleep occurs during nap 1845 14:38 ones. 03:16 Hypnogram Wake ~ Ne nS REM TI7AM—GSIAM—OZBAMIGZUAM—TST4AM = «1ZOHPM «ODPM 187 PM Page 2 vd BEPSL9BSBE © ZO TAL /LT/ZT‘Ochsner Health System Sloep Center. Tel: 804 842-4010 Baseline PSG/MSLT REPORT Pationt Name: Bodin, Jeffery Clinic #: 2592229 Date of Study: 2/2/2015 Ughts out clock time (arin LUghts on clock time (ami: 5:49:32 AM ‘Total Recording Time (TRT; in min.) 425.3 Sleep Period Time (SPT) 70180 Total Sleep Time (TST: in min 401.5 Sleep Eficiency 94.4% Sleep latency (St) 0:03:30 ‘Total Stage Changes (ater sleep onset 101 ‘Awakenings (after sleep onset): 2 WASO (min): 203 REM Periods 6 REM Latency": 100 (bpmy 1.0% 90 ~ 100 (bpm) 1.9% 80 - 89 (bom: 13.0% 70 79 (ope) 26.4% 80 ~ 69 (opmy. 21.8% 50 ~ £9 (opm: 24.7% < 80 (opm): 11.3% % Astiact / Bad Data 0.0% ome 498 0.0% 0.0% 0.3% 0.9% 3.6% 33.3% 61.9% 0.0% m3 0.0% 0.0% 09% 73% 38.2% 25.8% 2.3% 514 52.3 0.0% 0.1%. 0.0% 0.1% 1.1% 37% 10.9% 11.8% 317% = 81.3% 546% 82.2% 0.0% 0.0% ‘Count oO 0 ° ° ° ShonwetEwnt(minsec): NA NIA NANA Na WA NA OWN LongestEvent(minsec): NA NIA NINA NA NA NANA Sum Duration (minsec}: 0:00:00 9:00:00 00000 0:00.00 900.00 0.00.09 0:00.00 000.00 ‘Absolute Max Rate (opm): NIA NIA NANA, NA NA NA ONIA Absolute Mtn. Rate (bo NA NANA Na NANA _twa Pages zsetOchsner Health System ‘Sleep Center: Tet: $04 642-4910 Bi PSG/MSLT REPORT Patient Name: Bodin, Jeffery Clinic #: 2852228 Date of Study: 2/2/2015 Hypnogram Ei pH HH 30MM 1IAAPMZ45AM 145A BAAN BMGAM AABN sa9Au NOAAPM | (MMAPM | I245AM TMA 27M SMBAM | AMBAMSAQAM JOMPM—TTANPM | A2MSAM SMG AM 247 AM S4AU | AMBAM | EMOAN TOMMPM —1148PM | TRASAM AG AM 27M SMBAM = AMBAM SUDAN Page? 6z/et vd aersisases §— azZB Tz8z/LZ/ZTPOND ZEIT eso TE TREE, pei PISO DOTHEEEREY THPRARAGON, Fe setzrz109 Inti PA pc iam ariez02t ‘Surnmary of Care 7345-381 (a Documnt information esyee hte Soars votre Do tied fe” ime A mo A ae — niet of Toume MD Anderson Cancer Centar bees eae pn mM Buena Tein State as, ‘Sin ens seca Gey Bech SS, ern tnt cancer een Howton TRITOO marae tenes one notice putea Becerra Senha ee ical Sapp oo sen coco ' retereret Sao Ma Su uO Ohi waren! HERES Bsteceeese. Seer faeces ei a mo ncn ar cae Beane, soacn perme of Tatas MD Anderton Cancer Center Heuston 7039 Pa RaboceaLCampantas PA Prysican Assan) Taran oo (wae) himeaatt Gat 116 Holcombe Bue Houston 1% 77030 eps tnaveevarywhare ep com 2a B2/tT avd ecrsisses © 28 1207/7 /2Treser W218 Yt rie72021 Ma Merce naas, MD Prion) IS" e000 wore re a S85 Holcombe Bet Neveton 1 7030 Maanoma sugery untclan Orie on inieaiy of Texas MD Anderton Cancer Conter OS itscombedounard Heuston 177030 urge Vion RA (tending) SFT Hocemes pounars Heuston TH Nong hnpetareaveryuners ape com ez/2t bv ‘Summary ot Gere Blas ee ee on, yet est PIRES a RE JBFEREY THOMAR BOON, . evcoume: Dae Sep. 02 2016 arscaaces ez:ze Fax: 9853272100, woz seeraneabar PRT inte veonPAB ABE con SPT PERL THOMAS ROPE san cars FAR SES272100 Jeffrey T Bodin bore a Co ree 2 Patient Demographics - wer: bom may 221997 paar dress. conmetion Lunguoge face tery wwe sat ‘SUE RAU GENE ORive 5.520.479 Work) Angish Prefered, ‘inte Nor Hapani or ata. Single MANDEVILE CA OTT Note from University af Texas MD Anderson Cancer Center Ts dace coi formant wa Shed th WT Boman emi he we cr amr fos MO An Cac Reason for Visit Faliowip: Fotow-up Rowing Sues son Spreaty Diagnoses Precedunms Refered By Contac Releee Ta Comtact, Ged Paimomlesy Saunas: Murty, Vike CPA —talechancan Dr, Reap {SibHocembe MB. souvard Ss Holeambe abe Heuston TA77030owston 77050 Prone 718 792-4018 Prone: M2 7a4015 ReTtsea Rais s- 386 sf Encounter Details Oe se. Decarmece carers voriwao fee ait Gailopuimonary Corer ‘Morphy, Vee Cha Bis tocanoe bee 1S8P icone Suter Main tig fen Ror oven 77090 Sacer Fibersaeas ston. 77020 Tas ae) mbseao%5 Satacuandean, iaaker. MD ‘sts rolconbe oe Houston 1x 77080 rivers eke Medications - documented s of is encounter rasses 2 of 08/162021) eseasor S9 Dsvensed ats sans ipranbyirAMINE BENADRYL 28. Chew 125 mg amended. Raported on ° seve ing cheese abit Siro {Golnine useazene (OMNSTAD 127 hale pray ito cach now’ ° osrs01s ewe SEmegspmy ery saad eaten UEINDO 60 mg 12 We Tate 1200 mg by mouth as nade ° pene oe eporad on W540i" (MonENAR SINOVIAI 10mg Tae 1 tablet By mouth aay. ° rorsaais seve apatadne PATADRN 02% sro Acminitar1 opto Bat aes a6 ° esesrais pewe Shae saute ‘eased SEES e ee earereetie SABRINA [Active Problems - docuranied a lth anceanter(atsee 9 08/6/2021 Social History « dossmenud aso hs eco Tebaco vse a ei Years a. secre = Never Aen i nipsvinareoverywnere.epc.com “ szyet ova sepsisases © aciza Tac /z/ZTcoer EU errs eu PETE pcs wean v non TARTERL TOMAR ROO, van sane FARE 3089272100 wredeet Summa ota — Last Filed Vital Signs soca inti ya sgn toning tine toes conments E Tse 58 era PEATET ase ” Toviani6 928 aM cor Tempero w-coas'y ertaaoi6 26 aM cor ' Amprerytate %3 fons sas as cor Onrgen than om snaoresae aM cot nna Orge=Conrnranon vane sorgertei 3700 tonwaore saa aa cor wor assem se tapaaes6 928 ane eor 00 Mas ndex ne svat 328 aM cor { Progress Notes - documented in tis encounter Nurse vvin € 10718/2018830 aM COT Naming Note i Minvrenase® eniog Date of Wate October 18,2016 ‘ion etn tse ‘Tere Bodin 91970, male who pases with 10 hour lp tngh me andslee up 6 nos inthe moring ersten Fela es Review o Sater SPs bam reroncaty gre oy Mure Viean & 0/8/2096 424 2M oT Fan of Treatment -sonrena we eur eo / RRSUIRS - documented inte encour evan fe Siagcei, Visit Diagnoses -documemes inthis encoueer warecleoss, 86 tree Soeced rps.ienaveoverywhore epic com 24 6z/pt Bove aepsisases © @zZ8 1zaz/1Z/2Tre Ben as sees UGE PT pine vn EES wane SP ERTL TOMER, resseass RE SOEI7E0 anezaet ‘Summary ot Care scutiare eforston pec peters nape Sant ‘ erate esaces ees sakes cto Fe scacune Sees Hears Boe eee acta on tan main ee meet alee rea ieee uma he cee, eee a sate ce came EES. Recents Me Cyetha & Hersog. MD (Phyo M3 Bese6i0 wore ‘T3sas:3a00 fad) 138 Holcombe Bt Houten T7030 Pease Meiene ‘reer faa 0 Andersen Canc Care uton 77080 Ma Joho M. los, MD Physician) TBE a9 wor 13:ta5-4985 fy ‘ste nolcambe Bes Houmen. x 77090 Pecate Medne Unverity of Texas MD Anderson Canc Concer SiS rolcemve Sours owen, 777090 Ps Bian M Rives, PA(Prycicinn Ao) Tastee ste twone T3.t4s-381 (hw S38 Holeams fs ‘roustan 779030 ‘Surges! of Texas MD Anderton Cancer Contr Sete Tolcombe houeare Houston Re T7030 Pa Rebecca LCarpentr, PA Physician sista Peete woe sis Holcombe ve Houston oc 0s0 Stipes Oncology of fates MD Anderson Cancer Caner Seis holcompe boulevard Newton 7080 nd Steven Wagunapac, MB (Pryicin) 3 Ses"7eco toed 713.563.0664 Pa {sts moicembe Bis Nouston Te T1030, Fndoerneloy nipsusnareovarywtere encom a 6z/St 3d acrsiseses §©— 2:28 TZAL/LZ/ZTee ESSN ans ins AER nin von TRS sane SPATE TH OMMER RD nascar Fi bee ‘ane ‘Sanmary of Sie Ie Memiet Ross mo yin) enesen fe TEA Holcombe is owiton ir ra88 Ndenema Suey ereny of fake MO Andarson Cancer Came eerteieine! ep eu: Raza, MP (use Praiione) TBoeresio won ‘-re:sa00 (0) 151s Holcombe Boulevard Mounion 137030 Paaure Medeone of Temas MO Andareon Canc Cantor $e volcambe boleves ston 798 Caocian rgsnaaten University of Teas MD Andarson Caneer Cantor SSS Holcore vouesers Heuston T7080 facoutin Prides fecouier Due ap Outer Mo den eet 713-792-4015 (Word ae primed Tas 2586 (ra {Bistcenbe bt voson Te 00 inom Matone ntpasranareeveqrnere.episcom 62/3t | 39¥4 aerseseses © az'Ze teez/ee yetsree Batt ‘arenes Jeffrey T Bodin Summary ct Cre. geverate on aug, 16, 2021 iy Patient Oemographics - vee: born May 221987 Puan Acres Gemmoncaton Lasguage SQEeeAUCHENE Deg 585-520-4798 ocd Tnglh Pieter MANOIVULELATO@7 585-272-8588 Mode) tberboae Segmelcom no LE STP recite win, PRE DAP ye ars ESTUPEEREEY BERNE ROB oly amen Ts document conta information mat wa: thre wth Salty T Roce. ema ne canine ani cod rom Unvaty f Teas MD Anderson Cancer a from University of Texas MD Anderson Cancer Center Encounter Details Oats Type Devan Twos Telephone Srdeasimoras ctr Allergies -documenid 4s ofthis encovte (annus a of 2016/2021) Ne Keown Ace Alleges gy Medications - documents sof ns encoun (atts as of 0878/2021) Meseaion sa 2aoensee “Eihentvari BENADRYL 25°” Ch 12's a ve Rago on moccasin US Tay ‘Bnaernetiiatona OVMISTE 137. Inale 3 nto each nla Breahomy sry ress urDNetn (AUEINDD 620 mg 12 Taka 200 by mouth a need a Meporas on Vat 2007 rmomteitat SINGUAN) 10mq Tk 1 tablet by mouth diy. Slgpaadive PATADAY 2X drop Administer 1 drop to bath eyes as ‘phtbale slaen eeses, Active Problems - documented fis encounter tua a8 o 9/16/2001) Noten fie Social History - documenies ato tc encounter Tebeec te Type Prcnay Never Ress Last Filed Vital Signs -cocumenteein is encoun: Noto te Plan of Treatment -dorumenine as as encounter Not one Results - decane Noton le nps:anaceeverywnere ep <0 6z/et 300d Satechondran, Dtwaher, MO Sts rolconge ave Fewer tT rissa FS 88 rd atts Sap pate Sedu Sau ° ‘Ai ° ownazors deve ° roses deive ° osposrors dime! ° oasa016 Acie aersiseses © az:z@ Teaz/z/2Ta or st OTT Spee onan = TB SE see TERE ORME ACM ay sh SETAE Document Information fey Ces te Oar soa rena Daina Corge Dam tetas hn Pa yin oma toca Sivan. locker Seer of Re Mo Andre Caen Canter FE T.aem wow ii tatere peuce Hopes a on Sr Ro ae ad ey WP ase Main Newson Ferme Wee University of Tomas 723-785-9898 a) Lasers of Tots atoo x home oe Be Aatera ecw, Te Tae Sirettasenoe — OneBRY Boulearé Unieriy of Texas MD Anderson Cancer Canter Revaton srs loeembe Bouyer TBO ean PINE Hecog, Mo (rican) 660 Tinesa pes” Isis soiconbe be wouston Te Peso Feostre megeine ‘Univers ef Tones MD Andarson Cancer Cantar ‘Sts nclembe bode outon Te 780 ‘Md Joba M.Sopte MD Phyicard Hi raesio wore Ti 745-038 ar {ts molombe Ss sowron 77050 ‘river of enas MD Anderson Caen Centar {Sisteonbe Sovnore eumton 77090 etree pmo aorataes Cue, ae oe ects ae fp fates Carper 68 rs Asian Tiasz-eaao ener Tiasaee fad {sie Hekeerbe bs Houston 1 77080 ‘oresogy hy of Taxa MD Anderson Cancer Center $STSHoleorbe bovevs Houson TK 7RS0 aa Suave 40 (mysoans m5 Se3 70 ‘Ti.Se.o6e4 Fan {535 Roleame Bird owen Ti Ta30 Undoctolony Univmity of Texas MO Anderson Concer Center {Ee Tolcomae baceers Hoveten F738 Iipeuanareaverywnere.epiocom 2 sz/et sve eersigesas © @z:70 T20z/Z/ZTSESE as vores ESE MB cians w ron —PPRE HEE i coos HOTUEERGEY DAQMS RBM cas vs 9888272100 areca ‘Summary of Cae Med Marr hoes, MD Physica Ma sr eno wore, 79.745.500 fad Bite reicombe Bird Howson Tx 77030 Matera Surgery Univemty of tata MD Anderson Canc Canter SStErolcorie Np Sentra Waza, NP (Nurse Pact tone) "Btrerseto wong Ta.15:5000 (ron ‘51s Hokembe Boveard Wovaton 177030 Peat Maciaine ot Tens MO Andarsan Cancer Comat YerSolcembe Boulnard Guatodan igencason ot Taxes 1D Andervon Cancac Center {eisreleorbe Boulware ouston T7730 encounter Proves ecounte Date MO Dlwaker Balchandran, MO Attending) Now 18,2018 MBcaamts woes 71375. 2836 fa gts Mowombe Bt Houston 7080 Rony Medien mmpsthareevenrmere.epx-com 62/6U 3¥d gergegasas §— ez:ze 1az/ez/eTSMAI WEEE wis ACERS Spcme ooh MOMS vio EX TIME ERIN asc PG LTE eects ‘Surrary of Care Jeftrey 7 Bodin Soman of Care. ganaated on Aug 16 2021 Patient Demographics = tae bom May 221957 romezae , aemunarion angie face ey arta Sue MANOEVELLE. LA 70471 (985-272-8089 (Mobic) — ieee boltecereatere fienoan Opal com Note from University of Texas MD Anderson Cancer Canter ‘ie dcumart centurion tht was shared with Fey Bod. may nat conan he eee reer fom Urry of Tews MD Arderson Cancer G@ Reason for Visit jens Fostow-up Routine) ‘Sate feasen Specaty Capron /Meceaies Setered By Contact Rares 70 Cort loved Pulmercoay Pisonoses Saucrandran Omeler, Balachendcon Divak, Rareaessy wo: i Narcolepsy not STS Hokombe Bd S15 Noleombe Bh ‘Gmarwse pected euro T7083 Hounton 77080. Prone TIBTRaDIS Phone 718 7IzM01S FaeTinvesoase Rae a TeS2956 Encounter Details ate Tyee Depecueent ‘are eam, ovarrow Oe vist Cardopubmonany Center Balachandran, Oak, MO S318 Haleombe Bho {S18 Hokie Ow ‘Main tig 6th Hor Houston 1 77080 ‘Sewer Netsewors Heuston 14 7030 TETaS 2956 a Srrse-anns Allergies - socumentes as of his enconer statuses a of 08/16/2021) No Known Active Aeros [Medications - documented st ot his ercovnner (mates ax 2 08/16/2021) Meseason 33. 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MD (Physician MS Sbres10 wore Tacrassaoo ae S15 elcambe Bd Heusen 17080 Pot Meare Uniamty of as MD Anderson Canc Caner 1s iatonne teva Me John M, lope MB Physica 3-75 sei ore 3765-05 Poo JES socombe Be Houston TX 77080 feanaodce Univers of Texas MO Anderson Cancer Cont sts meleombe Bovleare ouron 177000 (Bian Risa, PA Prpcan Aasiart) Taoesers wore Tasasaer fad {sts rocambe Siva ousen 77080 Surges! necogy ‘of Takes MO Anderion Canc Cont ‘sis rokonbe Boueare Hatiton T7039 ‘Pe Roce | Capen PA Pian Asa) Tancaatt foc 818 Mleambe Bs ourton 1770 Oneslogy ‘iter of Stee MO Anderson Cnet Contar Ssts rokombe Boulevere outon: 1x70 sere eget Mo Pc ane usa en, eer Se oem ranocans cr rpeunacwaverywnareepiecom Pn cn ZH z/ez 20 cevez Ov ecrsiq9sos © eztza 1202/