L n. m1. Aetna Summary of Evidence, page 1 of 2 SUMMARY OF EVIDENCE IDENTIFYING INFORMATION Teffrey 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 (Exhibit C) was mailed to the member and faxed to the provider. On December 03, 2021, a 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 F).‘Actna Summary of Evidence, page 2 of 2 On December 30, 2021, the appeal decision letter (Exhibit E) was mailed to the member. RELATED DOCUMENTS ‘Aetna Exhibit A, Prior Authorization Request ~ 2 total pages Aetna Exhibit B, Guideline ~ 7 total pages Aetna Exhibit C, Notice of Action — 7 total pages Aetna Exhibit D, Appeal Request ~ 45 total pages Aetna E, bit E, Appeal Decision Letter ~ 9 total pages Aetna Exhibit F, Same or Similar Specialist Review- 3 total pages[PA History - Member 1b: POZM00000144408 == = ‘arama | onan: [Gexteouue | fromm. arvana SA cme EERE ono [emowr or aon » = aera 1 Jsosacire |.errneveonm) 2782) caret laa ROME lomcat omy Cem x. FORM Ino | Fras! { 4 4 | esziee [ereercon SSREIT foro fn scien rev aco IE perience EE oy Ine [pees [er [ProrRaboneaion Dea sacs a fcc feces pros emer City funoevice fnsersoso fa = aa Prrncan St i Frmacan aaDarra Org aaa DETROIT ANNE SOTA [Reqoesea an. coe Papporea an. [esse Locied By Imari Ieee herer ci [cannons ao rysion Vorb notation Da [cam No Canoe is‘Aetna Exhibit B, page 1 of 7 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®), modafinil (Provigil®), pitolisant (Wakix®) or solriamfetol (Sunosi®)|: For dexmethylphenidate ER capsules (generic for Focalin XR®) - 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, etc.; 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 true 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:Aetna Exhibit B, page 2 of 7 © 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; 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 altemative 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 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. 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®), nt (Wakix®) or solriamfetol (Sunosi®)]: 12 months or up to the recipient's, 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 Older: * 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Aetna Exhibit B, page 3 of 7 © 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 ©. 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. 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 [except armodafinil (Nuvigil®), 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: © 17 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‘Aetna Exhibit B, page 4 of 7 ©. 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 6 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. Reauthorization Criteria for Non-Preferred Armodafinil (Nuvigil®), Modafinil (Wakix®) and Solriamfetol (Sunosi®) Provigil®), 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.; https://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: MeGraw-Hill; https://accesspharmacy.mhmedical.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.Aetna Exhibit B, page 5 of 7 Revision / Date Implementation Date Single PDL Implemented May 2019 ‘Added specific wording for use of Focalin XR® and ProCentra® /November 2019 | January 2020 Removed POS information, added Wakix®, formatting changes, updated oe references / July 2020 wy Modified to apply new age requirement for behavioral health clinical authorization, | 5.527 o991 updated references / September 2020 ary Removed preferred wording for ProCentra®, formatting changes, updated references / November 2020 comes ‘Added wording for Sunosi®, formatting changes / September 2021 October 2021Aetna Exhibit B, page 6 of 7 vaetna AETNA BETTER HEALTH® Coverage Policy/Guideline Name: Quantity Level Limit Guideline Page: Lof2 Effective Date: 6/1/2019 Last Review Date: 02/2019 Cicalifornia Florida Dikentucky Applies to: louisiana OMaryland OMichigan Orennsyivania 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 spe 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 0Aetna Exhibit B, page 7 of 7 vaetna AETNA BETTER HEALTH® Coverage Policy/Guideline Name: Quantity Level Limit Guideline Page: 2of2 Effective Date: 6/1/2019 Last Review Date: 02/2019 california OFlorida kentucky Applies to: Louisiana OMaryland Michigan Pennsylvania Ovirginia Dtexas © Request meets one of the following: Requested dose is included in drug compendia or evidence-based clinical practice guidelines for the same indication + Apublished randomized, double blind, controlled trial, demonstrating safety and efficacy of requested dose is submitted with request ‘© 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 Dos: © 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 (© Requested dose is considered medically necessary Approval Duration: Prior Authorization | Duration ‘Quantity Restrictions | Additional Requirements ‘Approval Initial ‘One year Renewal ‘One year Box Warning: N/A REMs: N/A References: inActna Exhibit C, page 1 of 7 Aetna Better Health of Louisiana 2400 Veterans Memorial Blvd., Suite 200 Kenner LA 70062 JEFFREY BODIN 928 BEAU CHENE DR MANDEVILLE LA 70471.Proprietary Aetna Exhibit C, page 2 of 7 2400 Veterans Memorial Blvd, Suite 200 7H oe 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. If 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 isProprietary Aetna Exhibit C, page 3 of 7 effective. The preferred drug list 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.1a.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 doctor or someone 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: iaProprietary ‘Aetna Exhibit C, page 4 of 7 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 I 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 o entender esta informacién, sirvase llamar al 1-855-242-0802 0 TDD/TTY 7-1-1, entre 8 a.m. y 5 p.m. Dé dugc giip phién dich ho&c hiéu phn nay, xin goi s6 1-855-242-0802 hogc TDD/TTY TAA. Sincerely, Prior Authorization Department ‘Aetna Better Health of Louisiana isAetna Exhibit C, page S of 7 cc: KEVIN MCLAUGHLIN 106-MA102LAA1 12162019 ie Proprietary‘Aetna Exhibit C, page 6 of 7 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. Aetna: * Provides free aids and services to people with disabilities to communicate effectively with us, such as: © Qualified sign language interpreters © Written information in other formats (large print, audio, accessible electronic formats, other formats) + Provides free language services to people whose primary language is not English, such © Qualified interpreters © Information written in other languages Ifyou need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card or 1-800-385-4104. If you believe that Aetna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our Civil Rights Coordinator at: Address: Attn: Civil Rights Coordinator 4500 East Cotton Center Boulevard Phoenix, AZ 85040 Telephone: 1-888-234-7358 (TTY 711) Email: MedicaidCRCoordinator@aetna.com You can file a grievance in person or by mail or email. 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 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://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. 1A-16-09-02 f Proprietary; - ‘Aetna Exhibit C, page 7 of 7 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: 711). SPANISH: ATENCION: Si habla espafiol, tiene a su disposicion 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 frangais, 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 ¥: néu ban ndi ting viét, cé cdc dich vy hd tra ngén ngtr mién phi danh cho ban. Hay goi so co & mat sau thé id cita ban ho§c 1-800-385-4104 (TTY: 711). CHINESE: Eek: SURE RHE NC, GOT te AOSHI. GABE ID RAH st Wak 1-800-385-4104 (TTY: 711). ARABIC: 3p yall yl gle: Seattle Al Ag dy AN Bae a SLs ob dy pall Maly Sooas aS Hf ib yale ATUL :pSal 5 pmall) 1-800-385-4104 Je 3) {od atlas als ‘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 o sa 1-800-385-4104 (TTY: 711). KOREAN: F 9): SHOE ABSALES BH, HO A el MBAS SES OSHS F ASUCE HOt w 7S S| MO} QUE WS SUF 1-900-385-4204 (TY: 711) Oe Bee SAAS, PORTUGUESE: ATENCAO: Se fala portugués, encontram-se disponiveis servigos linquisticos, gratis. Ligue para © ntimero que se encontra na parte de trés do seu carto de identificagZo ou 1-800-385-4104 (TTY: 711). LAOTIAN: ugau: adaxiudawasaada, nawSnugouiedawane, tovtieesa, ciuihioutiean. Ynnaionbiddnugighouetnfoeesyiny § 1-800-385-4104 (TTY: 711). JAPANESE: JERI: HANGRE BAI SIL, MCHA R— bOP—- CAS CAMOREI ET. IDA — FRO BABS. & te ld 1-800-385-4104 (TY: 711) & CCH CES, URDU: ye oles ce oS oS I OLS OS ae hee Ob) Soe ce ol nS duly (TY: ri Lao sésai0 OS ees WS Ss al GERMAN: ACHTUNG: Wenn Sie deutschen sprechen, konnen Sie unseren kostenlosen Sprachservice nutzen. Rufen Sie die Nummer auf der Ruckseite Ihrer ID-Karte oder 1-800-385-4104 (TTY: 711) an. PERSIAN: 2402 cSt 0itls pu ns tl 5 SUS Sled a SENS ge BI Sy pe de aS ge ce eH Ob SI Bs Glas (TTY: 71.2) 1-800-385-4104 » tat bb shel SY poate RUSSIAN: BHUMAHHE: ecan abi rosopue Ha pyCCKOM AabiKe, BaM MOryT NpefOcTaBHTe GecnnaTHole ycnyrM nepesopa. NoasouuTe no HoMepy, yKazaHHOMY Ha OGpaTHOli CTopoHe BaWeH MAeHTHdHKA_AOHHO! KapTONK, wn no Homepy 1-800-385-4104 (TTY: 711). THAI: damsseiy: MAMYaNT ne AMAIIIO AVIN SH UUMAaN WATT ANS Tnsfinsiamnuaniarsrundsiins ID vase WaaMuwiAay 1-800-385-4104 (TTY: 711) LA-16-09-02 18 Proprietary‘Aetna Exhibit D, page 1 of 45 ‘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 a medical study he would like to submit for appeal as well. HP provided fax # for A&G LA. 19‘Aetna Exhibit D, page 2 of 45 Kevin E. McLaughli M.D., D.A.B.S. 350 Lakeview Court, SuiteA | FAX ELD Covington, LA 70433 —— Phone (985) 845-2677 BEC 27 2021 Fax: (985) 867-5498 FAX TRANSMITTAL (DATE: TO FROM (company: Coho Qppatts Kevin Mclaughlin, M.D/ Assistant Regina S. ATTENTION: Ashley 350 Lakeview Court, Ste A Covington, LA 70433 | Phone 985-845-2677 (ext 208) FAX NUMBER: 8(K) - (00% = 1057 | rax No. 985-867-5498 COMMENTS No. of Pages Transmitted : (INCLUDING TRANSMITTAL FORM) The documents accompanying this telecopy transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosiog this information to any other party and is required to destroy the information sz/1a 3ovd 20 afler its stated need has been fulfilled, unless Otherwise required by state law.if you are aot the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance oa the content of these documents is strictly prohibited. If you have received this {elecopy in error, please notify che sender immediately to arrange for return ow these documents. eepsz9asas §— 8:78 TeaZ/LT/ZTWhatereab, ‘Aetna Exhibit D, page 3 of 45 Prior athe wation Needed 4390 HIGHWAY 22 MANDEVILLE, LA 704719317 Tol; 986-674-2551 Fax: 985-674-5336 Date: 12/17/2021 rim 2:99 PM Preseriber information: Physician: KEVIN MCLAUGHLIN Phone: 985-845-2677 ‘Adaress: 950 LAKEVIEW CT Fax; 985-867-5498 COVINGTON, LA 704097522 DEA#: BM6269557 Patient Information: Patient: JEFFREY BODIN ‘Accra 828 BEAU CHENE DR MANDEVILLE, LA 704711777 0522997 985-272-8989 Prescription information: Fx Number: 2501425-05982 Requested P/U Time: 12/17/2021 02:51PM Drug: D-AMPHETAMINE SALT COMBO 30M ay: 90 TABS Last Refi: 12/17/2001 Generic For ADDERALL S0MG TABLETS 89: TAKE 1 TABLET BY MOUTH THREE TIMES DAILY Maszaas: Pran does ro cover tis medicaton, Pease cal ‘change medication. Patient ID # is 57940386456 1 at (855) 2642970 10 initiate prior authorization or calvtax pharmacy 10 In accordance wits tate ‘equator pera wi be wdstivtd wiles cha wie Indicated Cddeponse as Weitere Macicely Necessary Please fax back to Walgreens al: 985-674-5334 ‘scam tae a pe 6 test ce mR A Mer al ee we Be CH Wd bere ek itaing of ummm mt ote be eases oat neous vce a Yo we hy ses maton SaPOEE 8 OOD DuRSacian deinen PMOSTEG tow ced amano tea oe ena 62/20 vd esrszseses © @z:za TZ0z/zz/zt a‘Aetna Exhibit D, page 4 of 45 moeenae” | b/ yk Soames flee Tuly #2 Houston, TX 77030 Phone: 713-792-2352 Multiple Steep Latency Test Report 1 PATIENT PROFILE Patient Name: Bodin, Jeffrey Height: 168 cm Weight 60.0 Kg BMI: 17.7 kgim2 ‘Study Date: 8/5/2016 Referring Physician: Dave Balachandran M.D., M.O. Epworth Sleepiness Score (ESS): 14.0 DIAGNOSIS Hypersormia 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. Ouring the baseline polysomnogram the sieep efficiency was 77/5%. There was no evidence of clinically significant sleep disordered breathing, noctuma! 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 5.9 minutes. There were four sleep onset REM periods (GOREM) noted. ‘The diagnosis of narcolepsy requires 2 SOREMs, and an MSLT score of iess than 8 minutes (mean sleep latency). An MSLT score of less than 10 minutes with less than 2 SOREMs can be seen in Idiopathic (CNS) hypersomnia, upper airway resistance syndrome, periodic limb movement disorder and sleep apnea. 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 of 2 6z/E@ B0vd Bersisesas §— we tza_1eez/Lz/ZT 2‘Aetna Exhibit D, page 5 of 45 ‘Ochsner Health System ‘Sloep Center. Tet: $04 842-4910 ine PSG/MSLT REPORT Sleep P thy #2 Patient Name: Bodin, Jeffery Clinic. 2562229 Date of Study: 2/2/2015 Patient Name: Bodin, Jeffery Hospital #: | 83000256150 ‘Sex Wale ‘Study Date: Dano DOB: SRIABT Gini #: 2592228 ‘Age: ir Referring Physician: | Uudmila Lysenko, WiD Holght: e700 Referring Physician # | 2478 Weight: 707.0 bs ‘Sleep Specialist: L Lysenko, MD. BM 76.8 Slowp Speciallet #__| 2478 Hypopnea rote:_| AASMIA Scoring Tech: ‘ABecnel RPSGT ‘Total AHL 70.3 Recording Tech: Leanett Sandifer, RRT Lowest 07 satic | 81.0% Recording Location: | Ochsner Baptist ‘Sleep architecture: This is a baseline polysomnogram. At lght's out, the patient fell asieep in 3.5 ‘minutes and slept for 94.4% of the time. Total slop time (TST) was 401.6 minutes. 8.4% of TST was in ‘Stage N1 sleep, 24.4% TST in slow wave sleep, and 21.2% TST in REM sleep. The REM latency was 69.0 minutes. Sleep archiiecture was milly disrupted due to underlying sleep apnea. itd snoring wes present. There was mild, yet significant OSA (obstructive sleep apnea) baved on Atl apnea hypopmee inden) tara. The overall AMT was 109 wih a Oxygen rac of 61.0%. ‘The supine AHI was 5.9 and the REM AHI was 30.4. The patient did not qualify for a split night study due noir Narr af vena hata a ofthe sea Motor movement / Parasomnia: Thera were no significant limb movements of sleep noted. The total limb movernent index was 0.0 (0.0with arousal). Cardiac: Cardiac rhythm monitoring reveaied a normal sinus rhythm Patient perception: On a post-sleep study questionnaire, the patient indicated that sleep wes “worse” in the tab than compared to home. SLT: Next day, for the MSLT 4 naps were recorded at 2 hour intervals. far appraximately 20 minutes duration each, starting at a ights 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'f/4 naps. The sleep onset latency for Naps 1 through 4 were 3:30 min, 1:00 min, 0:30 min, 2:00 min, respectively. The 4 nep-mean sleep latency was severly diminished at 1/5 minutes. The patient felt that che fell usleep on naps 1-4, Urine drug soreen fon the morning of the MSLT was negative. IMPRESSION: 1. Severiy diminished steep onset latency of 1.5 minutes was noted on MSLT with 4/4 SOREMS. (sleep onset REM periods). This is suggestive of narcolepsy in appropriate clinical context. 2, Mild, yet significant OSA (327.23) based on AHI criteria RECOMMENDATION: 4. Clinical corretation is suggt 62 /P@ BOVE 2 | Seber Liudmita Lysenko, MD 3 ez:zo eepszaese6. rwozsez/et‘Aetna Exhibit D, page 6 of 45 Ochsner Health Systom Sloop Center Tol: 604 842-4010 SGIMSLT REPORT Pationt Name: Bodin, Jeffery Clinic #: 2592229 Date of Study: 22/2015 MULTIPLE SLEEP LATENCY TEST: SET Analysis Start Time: 7:37:28AM 9:20:58 AM 1 ‘AM 4:40:28 PM NIA - Analysis End Time; 7:55:58 AM 9:45:68 AM 11:48:58 AM 1:57:28 PM NA - Time in Bed”: 18:30 16:00 18:30 17:00 NA 1845 Total Steep Time': 14:30 15:00 14:30 14:30 NA 14:38 ‘Steep Onset”: 03:20 01:00 00:30 2:00 NA ones REM Latency": 03:30, 03:00 93: 93:30 WA 03:15 "Time formats ara in min:eee. Note: report will ratuen default im Hypnogram Wate Mi 2 NO REM TSTAM—GSIAM—O2BAM—«1020AM = TTAAM = AZOBPM03PM 157 PM Page 2 67/58 Va Bepyseseses aziz TZez/Lz/ZT 24Aetna Exhibit D, page 7 of 45 Ochsner Health System ‘Sleep Center Tel: 504 842-4910 Bi SG/MSLT REPORT Patient Name: Bodin, Jeffery Clinic # 2592229 Date of Study: 2/2/2018. LUghts on clock time (arcmin): ‘Total Recording Time (TRT; in min): 425.3 ‘Sleep Period Time (SPT)*: 7:01:50 ‘Total Stesp Time (TST: in min.) 4015 Sleep Eficiency: 4.4% Sleep latency (SL): 0203:30 ‘Total Stage Changes (after sleep onset): 101 ‘Avrakenings (ater sleep onse!) 2 WASO (min): 203 REM Period: 6 REM Latency’ ooo 90 0 sao ant ms 2 ioe a Na waso MONON aR sage Darton (io in) Nt 00 Nz: 35 Na 140 R: 709 ‘Stage Latency =00 donates star of sloop Pages 62/98 3vd eGrsvsasas ©0778 Tzez/Lz/zT 5ezste ‘Aetna Exhibit D, page 8 of 45 ‘Ochsner Health System ‘Sloop Center Tet: 504 842-4910 PSG/MSLT REPORT Patient Name: Bodin, Jeffery Clinic #: 2562229 Date of Study: 2/2/2015 ‘Count: 6 2 8 e 6 2 0 ry Index (ovonte hr): O37 t) = os ms 00103 Moan Durstion(secy 128 «= WANA 199, 125 192 NA 192 LongestEwent(sec): 144 «NANA 447. 144 “47 NAAT REM Count 3 . 8 40 3 “a 0 3 NomREM Count 3 oo 23 3 28 0 26 REM index aa 00 op 28 2t 34 00804 Non REMIndex ee a eee! 08, 49 0049 * Note: Doss not contain Cheyne Stokes Breathing, Hypowentlaton, or Periodic Breathing Duraton (hre:min'sec): 30230 ‘0.00:00 0-40.00 2:69:00 ‘Obstructive Apneas: ° oo NA NA 0 09 & 00 NA ‘Cenal Apneas: 4 03 NA NA 18 413 NA Med Apness: o 00 =NWA NA 9 00 00 NA ‘Hypopneas: 7 OB i eR 2 a a7) Nn RERAS: ° Oh MIN 000 02 0b Wn tn Total: 18 59 WA NA 34548181 NANA * Note: Does not contain Cheyne Stokes Breathing, Hypoventiaton, cr Periodic Breaming 1325 1790 400 cr) 00 Sepine Prone” Lah Side RONMSCE Upiah ‘Duration (nin) BODY-POSITION RESULTS Page 4 werd esrsigeses © @Z 128 1Z0z/AZ/ZTAcina Exhibit D, page 9 of 45 ‘Ochsner Health System ‘Steep Center Tel: 604 842-4910 ine PSG/ LT REPORT Patient Name: Bodin, Jeffery Ctinic #: 2592229 Date of Study: 2/2/2015 Tote Sleep Time: 49 73 60 90 109° 163 Non-REM ” 32 28 53 45 BS REM 32 226 32 226 4452 “EEG Mousal actly no associated with Respiratory or PLM events Total Sleep Tim ° cry 0 00 0 ry ° 09 Mt: ° oo ° 0.9 o 00 ° oo Nz: ° 90 0 00 ° 00 o oo NB: ° 00 ° 00 ° 00 ° 00 R: ° 00 ° oe ° 00. ° 00, ‘Total Sleep Time: ‘Wake (after sleep onset): Non-REM: REM: BEos 13.4 0863919 OS6I G19 0854510 Wake Non-REM = REM 1st 7B (Oximetry Trend Graph 62/80 350d agrszgeses ez :Z8120z/Lz/ZzT a‘Aetna Exhibit D, page 10 of 45 Ochsner Health System ‘Sleep Center Tel: 604 842-4910 PSG/MSLT REPORT Pationt Nama: Bodin, Jeffery Clinic #: 2562229 Date of Study: 2/2/2015 62/68 Bova B 100.0 99.0 99.0 98.0 100.0 Max. SpO2%: Mean Sp02%: 964 95.3 96.0 96.4 95.4 Min, SpO2%: 91.0 910 91.0 00 ‘SpO2% <= 89% (min) 02 0.0 00 00 oz ‘%Time in range 90 100%: 974% 98.8% = 98.0% = 98.0%. 80-89%: 0.9% 0.0% 0.0% 0.0% 0.1% 70-79%: 0.0% 0.0% 0.0% 0.0% 0.0% 60 ~ 69%: 0.0% 0.0% 0.0% 0.0% 0.0% 50 ~ 50%: 0.0% 0.0% 0.0% 0.0% 0.0% < 50%: 0.4% 0.0% 0.0% 0.0% 0.0% ‘ Artfact / Bad Data: 12% 0.2% 1.0% 0.4% 0.4% Mean HR. (opm): 665 40.8 513 514 523 ‘%TIme in range > 100 (opm): 1.0% 0.0% 0.0% 0.0% 0.1% 90 100 (bpm): 1.9% 0.0% 0.0% 0.0% 0.1% 80-89 (opm): 13.3% 0.3% 0.9% 0.4% 1.1% 70-79 (opm). 28.4% 0.9% 7.8% 2.4% 3% {60 ~ 69 (opm): 21.4% 3.6% 38.2% 10.9% 11.8% ‘50-59 (opm): 24.7% 33.3% 25.8% 31.7% 31.3% '< 80 (opm): 11.3% 61.9% 27.3% 54.8% 22% % Artifact / Bad Data: 0.0% 0.0% 0.0% 0.0% 0.0% ‘Count: ° 0 0 ° 0 ° oe) ‘ShorestEvent(minsec): NA = NA NANA NA NANA NA LongestEvent(minsec): = NA NIA NANI. NA NANA NA ‘Sum Durston (min:eec: 0:00:00 0:00:00 09000 0:00:00 0:90:00 0:00:00 00:00 0:00:00 ‘Absolute Max Rate (opm): NA NA NANA NA NARNIA ON ‘Absolute Min. Rate(opm): NANA NANA, Nia WA NANA Page 6 eerazseses §—azize T2ez/12/2TAetna Exhibit D, page 11 of 45 Ochsner Health System ‘Sleep Center ‘Tet: 504 642-4910 Bazeline PSG/MSLT REPORT Patient Name: Bodin, Jeffery Clinic #: 2592229 Date of Study: 2/2/2015 1OM4PM | VIMSPM | IZASAM = LAGAM | ZA7AM SEAM 4ABAM SAM TOMSPM = TTASPM 245M TBA 2ATAM 248AM aan a9an Limb tovement Events patito — _ SS t 1 1. | AOAKPM = TTMSPMT245AM 2AT AMO SMBAM ARAM SABAM. Page? 6z/et Bove eepaugases §—@z!Za_1ZOZ/Lz/ZT 2‘wreraces Mo knee, Document Information Primary Core Pier Other Serie Prowiers inert meta oa ion Tis T-$80 Wor IE ot Toasaen os) {ta hecenoe Se voaron te edoone Sopa fae eaterse SNS Bauer iy Room 1177020 moe Sen a ‘Stave rae traccmoony Np Shin ty, NP hase racsioney hse3 0670 (for Tianras S606 ‘atoo'se sms Dre oust, T7058 ‘Uravenhy of Taras MD Anderson Caneer Centar 1515lllmbe Bouvet Housta Pe 84 Cyetia E Herzog, MD ryan) e610 (wore 73.745 Sato Fa 1835 Holcombe Bid Houston 177030 Pedavre Mesicine fof eas MO Anderson Cancar Center 51s nocombe Boueae Hotaton 177030 Md John M. Sip. MD yician) 3°79 S610 hr {eis Mokombe seule Houston Te 77080 Px bean M River, PA Phycan Assan) Tiree 5610 wo 73-745.3801 (ra 1815 Holcombe Biv Houston, 77030 Surge! Oncoiogy of Taxes MD Andarson Cancer Centar SSistokombe beubver Houston, 77030 Pa Rebecen | Campontes PA (PhypicianAcsitan) Ma-763 coco wna) ictus Sov (a) 1515 Hokembe Bid Houston, 7030 ‘Surpi Onealogy Union of Tatas MB Anderton Cancer Cater {sis Rocorme scien Houston, Be Ma Seren Wegquenpeck, MD (yson) 73 $63 Peco tore 71a-$60-0664 ac {StS Howombe ied Heuston 77030 {Undvesey of Texas MO Anderson Cancer Center "Os voleombe Soules Houston T7080 tpavtanareeverywhere epic com sett Bod 0 ‘Aetna Exhibit D, page 12 of 45, Sip. o2 2016 ecpszsesa6 ec:ze wore /etervoieviy ‘Summay of Core Ma More Ross, MD (Pi Ms "rreeeo werk ad Ta-745 3011 fac {ERE Welcome Bet Hovston T7030 Univer of fais MB Andarton Cancer Canter YSienokombe boulevard Houston Be 77036 Nr Betrs Maca, WP (Nerse Practtonen Tee S610 wos) T1378 $000 rw. 1535 Holcombe Boulevard Cuntocan Organization LUnivetity of Texas MD Anderson Cancer Cantar $sts Hocombe Bouvet Heuston 77030, encounter Providers Nurye Vivian ERM (Aten) 3515 Holcombe Bouinard Howton ‘using hpevfshareeveryware pie com szyet vd at Aetna Exhibit D, page 13 of 45, Freoumer De Sep.(2 2016 espszoacas ee:za reue/2z/20saat Summary of Care ‘Aetna Exhibit D, page 14 of 45 Jeffrey T Bodin Lines ‘Summaiy of Core, generated on Aug 16 2021 . Patient Demographics - Mae born May 22 1997 Part Asecat Conmuneation Language face tency arta ttat | SQB MAU CHENE DRWe 905-520-4713 (Werk) ngish Prefered) wn or tatna Single MANDEVILELA TOON Sara-aaBo bebe) fe/ Nar epee a thejbosie7 Symal.com Note from University of Texas MD Anderson Cancer Center Tris daqumere cetaing information that was shored with ftreyT Bin. Kay nat con the env cod rom Unis af Teas MD Andenien Canoe: Concer sesv0n Soscaty Clagoses Procedures fetered By Contact Retere To Cortact Pulmonology Siagoaes Vile CPA alachandran, Or, Naoto SBeNomee Ma ou Ws Mokombe ke Feoson 77030, Howton P0806 Prone TE MEd01S Phone Ta 724015 femasear foe Tatas 858 i Encounter Details : ox Woe Deoartmert ontam forenos ee ist Gardopuanary Caner Murphy, Viele cA ; ‘Bistlceombe be "S13 Holcombe Boulevard Man Big, br or euston 177030 Severe Traeohs Howton 77090 Tirso a) Tien Reason for Visit Revs Fotowip Follow-up Routine) sas [Allergies -documentes a of ht encounter atuis a f W/T8/2024) ‘aactundean, Baer, MD {sis Hacombe Ba Houston 1X 17030 Tipe ¢ NoknownAcweAlegis Z _ - i ‘Medications - conwmented a of ths encounter (auses as of 08/36/2021) ' Mesieaton 9 Dispensed tits Sut Dste Endgame Sanat CiphtysrAMINE (GENADRA) 125 Chew 128 mg as naded.Raperted on ° sete ‘75 chewable abet iano darineftasone (OYMISTA 127 inal 2p lat each nos as ° asns2015 dae Someahprey spy aude ‘usiFtNetin IMUCINDO 600 mg 12 Taka 1.200 mg by mouth as nese. ° pee Soe Reporad on Vai/2017 ‘mooueutest SINGLLAID 10mG Take 1 tablet ty mouth aly ° saesacis deve uber } lepatadne PATADKY 02% drop Administer drop to both eyes as ° 05972015 ‘etve ‘Spename souven ‘ede yam 300 mg/m soe, Se o [Active Problems - daciranta of ths mcoute tatae 2! 06/6/2021 Net on fle : ‘Social History « documented ss of this encounter Tobacco Use Sree uc Yuurs vse Neve Assessed — peaestnccremeatnees nitsehareoveryuhere.epki0%n we SZ/ET 3ONd sersuseses © ezize Teez/ez/eT 2wee! ‘Summary of Care — Last Filed Vital Signs . aneumannsin tis nearer es sgn Rew Timo tate Blood Reta i355 TUraRoie FAA COT se “ sovia2016828 aM cor Tampere ar-csa6y toyiaoiss2n aM COT aspraory Rate * saniarove 928 am COT nygen Stuation om sona2016 928 aM cor Inhaled Oxygen Conserravon Weight s0kg (1010 57 on) tonaz0%6 928 aM cor Begnr es cm 5 614) tanarzo%6 828 aM cor Body Mass nde mm Progress Notes - documented ini encour Nurse viean€_ 10/78/2016 930M COT Faxmating sts nove erent fom dhe oii Nursing Note Patient lly Y Bon age: 19 0, MAN 07a068% Attending ate of Vai Octnber 18, 2016 Wistor of Present ness: iefrey Revi o Stem ES ryt xan BF ceroncay signe by mute Vnan Em 10's 424 PM cer {& Plan of Treatment - Netontie Results « coumeine in Neton fe eumented ae ofthe encounter Visit Diagnoses - document in this encourter Diagnose at Naealepsy. 8 otherwise spaced Iipeztenarecverywnar.epic com SZ/PT 3b 3 18/2016 928 AM Cor Aetna Exhibit D, page 15 of 45, Commons 86»S298S86 al 1 fdins« 193.0, male wh presents wth 10 hous leep a right ime and sleep up & Rous in the morning itemiteny. Fels ted an tatgue. 26 a TeeneZ/etDocument information Primary Es rouse ate Sone overs ‘Md Meee Rong. re Lane Red, PA hyn Aci Beiolece sore. Sel onetogy me ideo of ae MO Andee Caner Center TSS8-s00 Word ‘SIS helene boderd 13-48-3001 ra), Houma ACTOS TSISMIS tai Loy NP Dre Pettone) roan Tyme Mestad ere Date ofRaae 15745-9806 0) Yprraizet las istcos ome ore Meat houton Tx Foss 1518 holeombe Oncology co Sera tae Mo Antenne attr oun 77080 Kerbs Selo Ma core rz. MD Ta be-s60 wort ae Tins sa red Bishcanbe Bed ounon ix 7850 Pedave Mearne prventy of ro MO Anderson Cancer Cnmar SS voltarbe soured Howmon 1277090 Md Jota M. Sop MO Phin) Hearse won! 7e:rs-998 {sitokonbe aa oon ix 77050 fess ediine Uaioe MD Anderton Cancer Care Ps Eran M Blues, PA Prin Aeare) aslsnokonze Soler Heuston T7020 ‘713-745-3001 (ras) 1515 Holcombe Bd Housan 77050 Tier ot Ra MD Ancaeen Cancer Center sts Hokombe Boulevard Houston 77030 Ma Steven a Mb (Pyscon) 3 563 7600 713-563-0664 (rag 1515 Molombe Sid Heuston, 77030 Endeerelogy myo Texas MD Anderton Cancer Cater Teton Be PFO80 tmtpsuisnareevenwhere epic.com 6z/ST vd 34 ‘summary of Care Aetna Exhibit D, page 16 of 45 Cocumont e. 18, 2016 eepszseces ee 220 cage Ones eons setorvwawes ‘Summary of Care — a4 meric Ross, sD (hylan) o ‘Tisae-eeo0 werk ‘Aetna Exhibit D, page 17 of 45, inacyas-901 fac | 1815 Holzombe Bed Houston BeTTODO Melanoma Surgery Unworsiy of Foss MD Anderson Cancer Cantar StS Wokombe balovre Newson Te 77030 Np Beane: Raza, WP (Nuts Pracione) Ty ee-se10 ors) ‘713-706-5400 fF) 115 Mokambe Boulevera Noun, 77030) Pedic Meciine University of Texas MD Andarson Cancer Center eis Mokeambe boueverd Houston 177080 ustocan Orgarination University of Teas MD Anderson Cancer Canter t E15 Holcombe bev Houston, Te 7080 ecoune Providers Encounter Date MO Divaker Balachandran, MD (Atencing) (oc. 18,2018 i TS-7ae-4013 (Wor Tatas 2886 fo 151s Hokombe vd 77030 Pulmonary Median heevronareeverywhereepc.com 6/aT Bove Berszseses ez zB TZez/Lz/ZT 35or ewaues ‘Summary at Gare Jettrey T Bodin ‘Aetna Exhibit D, page 18 of 45 of Car generated on Aug. 16,2021 : oe ee tient Demographics - Male: bom May 22 1997 | Patent Aceess Commuricatan Language ace / Sericry Mara tas ‘S20 BEAL CHENE DRive 985-520-4728 Word ral refered \Wilte/Not Hepani r Latina Snoe IL MANDEVILE-LA TOOT $85-272-0989 (Mabie) ttepseany Seamallcom Note from University of Texas MD Anderson Cancer Center “This docamect contains information twas shared wth fey Bod may ot cena the er record from Unive Teas MO Anderton Cancer Encounter Details ue Yee Omaavent con an : Niwa < Caropumoray cere amchondra, Otter | Taeon 1315 moicembe Bho S16 Holcombe Bhed Mun ouy on hoor Howen Pts Bevoor Tierseaais feito oc 77000 TTS 88 a) Fyoeaae Allergies -documenied a of iis encounter atuses oof 0/16/2021) [No Known ace alge Medications - soounerte a of nis encounter (tates 25 of 08/16/2021) Meseaion SQ Dispensed, Aelia Date tn Dae chen REUAORN 28” Sting Seda ses $ seen Sventnetvsavone OYWETA) 187 Lnat lo etch nia ° osnaaons So megitprey spy needed. {uaF ENedn OAUCIND 600 mg 12.4 Take 7200 mg by mouth os needed, ° acive bie Reported an 1/34/2017 i rmonteldast SINGULAR 19m Take 1 tablet by mouth dai ° 0/0605 sete ‘abtee slopes PATADAN 02% hop Adi rp bein ees ° esre572018 baie ‘palm shen ‘eeced ave ° Active Problems - documented gt this encounter (rates 48 of 0/16/2029) pes Paenaay ence Used ate ee Filed Vital Signs -veeumentan hs encour Neocon le Plan of Treatment - documantad ax ol ius encounter Results . decunertedin tis encounter Neton fe - _ : npsimacenvannae speci 1 seet aa ssvecasces §—oztze wae/Lz/2t 36Document Information Pury caster Qatar Ciegct tom” Seles toe had PA. nd wonrsiee. eae BERS ae anton Con cme FETE coven) Matabeeaoes Tene ee” oe meat EES ES pa img ne ane nace teeter siney Thsceaet eet Meee” ieee its oan tite 8 Tetsrolcombe Grae of Texas MD Andaron Cancer Cantar itt oman elecane tg meetin Home MO Pye see tee ses Bere, ieee eens Teer iso andron cnet Carer orate eae id Jobe M Spl MO Phys) vanes Sel T3745 4508 (ue 1515 oeorbe Bis ousion Te 7080 esite Medicine University of tas MD Anderson Canene Center {Bismokombe Bevlewre owston TH 77050 Pa rian M Rivers, PA Phyian Assinar) Mossesete ott Tans ent a Tes Holerbe Bis tourer 7030, al Onelogy ‘river of ges MO Andaton Canon Conter ‘sibtoanbe Sounerd Hovsan 171090 a Recon Carpenter 0A (Pian Assim) Tisrse ea00 wou) ‘Ti3:145-3801 fr 1535 Holembe Bis Houston, 77080 Surpes! Onecoay University of Texas MD Anderson Cancer Center StS comb Soules Hewat DCIS te an eganget MO Pin) 713563 7600 (Work a T13-865.0564 Fa. 1515 maleombe Bid omen oT 7090| Univrity of Texas MO Anderson Caner Comer sts wokombe baulova Houston, 77006 paanannavecyunore epi com 6z/8T vd a Summary OF are ‘Aetna Exhibit D, page 19 of 45 Doeument Coverage Dates Now 18 2016 | sepcz98686 aziza teecseZ/2tereever Sumehary of Cart” = Md Mere hoxe (ryan) ‘Aetna Exhibit D, page 20 of 45, easton 77090 eterna Surgery ripest of Tata MD Anderton Cancer Cantar ‘ists malcembe sauevte outer x70 No toutes Ras, use Petits Mormegete or ‘3:15.50 rn {is neeorbe Sours Mowon 788 Feaoot hectare cvs of Texas MO Andari Cancer Contr ereetame settee ouron e700 Sistodian Ocganaation ‘University of fae MD Anderson Cancer Comer i 1st5 Hokzombe Bolevor : Houston 77030 Encounter Powers Eecoumter ate i MO Dhwehr Balechandran, MD (tending) ow. 18, 2038, 73. 733-4015 Wore Medicine epeviohareeveryenareepic.com we 62/61 Bova esrscseses © oz :z8 1202 /2/2T 8wroraies ‘Summary of Care 1a Exhibit D, page 21 of 45 Fe ‘Aetna Exhibit D, page Bor cice geeratd on Aug 16 2081 Patient Demographics - ae: bom say 22.1957 : peer aires Sent: Friday, December 3, 2021 08:16 FM 5: Appeals and Grievances Aetna Setter Health Kenner <18606077657@rfax com> ut ct 2021-12-03 2615 Attn: Ashley Subj} Bodin 2021-12-@3_1615 Attn: Ashley Subj: J Bodin To, Ashley 18606077657@srfax.com From, Jeffrey Thomas Bodin 4950 ‘Acina Exhibit D, page 32 of 45 Jeffrey Bodin ‘Genserwaity amg Tis rempe itorsed cyte um oo naveaul o eiy oy Ke aaaeana, a ey Grain arraon wah ewes, rman Borel or exc fom Gago soe appt on you re net Veondoo way oe paren apres ti amie oe ed uN. Yu [e'atay pronto fom seoung dastatng cpingern ay my ng Wermemage You haw civ tiscarrumcnion er, HesN Ie ea Oey 5 elle ay cies you ay Pave roared.Actna Exhibit D, page 33 of 45 Curr Treat Options Neurol (2015) 17.20 Page 3 of 12 20 Table 1, Medications used in the treatment of narcolepsy Org Starting Maximum Comments dally dose daly dose (mg) (9) ‘Norepinephrine reuptake Cardiovascular and sexual side effects fenton ocuing SS, SHRI and TOS Venlafaxine Mo 300 ‘Rebound cotaplery Can occu on dlscontiaugtton.. z ‘Available in an extended release formulation Atomoxetine 10 i 80 Usually given twice par day Amphetamine salts (Adderal), ES 60 A combination of four amphetamine salts Methamphetamine (Desonyn) 15 80 “he strongest amphetamine with strong abuse : potential - Dedroamphetamine (Dexedrine) 30 60 (Often used as PRN docing for additive EDS benefit Usdexamfetamine (Yyanse) 20 70 ‘May be better tolerated than other amphetamines Methyiphenidate (Ritalin, 30 0 Proferabie before using amphetamines CConcerta/Metytin, Equasyin XL) Dexmethyiphenidate (Focatn) 5 20 ‘The d-hvee-enantioner of racemic mettytphenidate Modafinil (Provigil) 200 400 fitst-ine medication for EDS ‘Armodafini (Novi) 150 250 First-ine medication for EDS. Longer acting than modafinit. Sodium oxjate (Kyrem) 4Sg/tight —_9.0.g/might Fist line medication for either EDS or catapleny Seleiline (Eldepr. Zelapar) 20 0 Used mainly in Europe. Breaks down to “amphetamine derivatives. Needs low ‘praiine diet Mazindol # 6 {A tricycle, anorectic, nonamphetamine stimulant Pitan 10 rs Wot available in the USA ‘selective histamine H3 receptor inverse agonist ‘Not available in the USA Ses sertonin-norepinephive reuptake inhibitors, SSRs elective serotonin reuptake Inhibitors, TCAs rete antidepressants Treatment “Treatment decisions are driven by the presence of EDS alone or EDS with other REM-sleep phenomena and additional symptoms, since a single therapy that is effective for multiple symptoms is usually preferable than using differen drugs {for individual symptoms [28]. Sodium oxybate Is only approved in adults for EDS with or without cataplexy; however, evidence indicates its utility for DNS and as an option for other REM-sleep phenomena such as frequent disturbing ‘dieams and nightmares, hypnagogic hallucinations, and sleep paralysis (18, 19) EDS as the sole inftial symptom EDS is most often the presenting syinptom, and when it occurs without cata- plexy. the considerations include the use of modafinil/armodafinil or sodium.