A review of the records reveals the member to be an adult male with a birth date of 08/02/1950. The member has a diagnosis of bilateral keratoconjunctivitis sicca (also referred to as dry eye syndrome). The member’s treating provider, Lucian Szmyd, MD recommended treatment using the prescription medication, Restasis.
The carrier has denied coverage of the prescription medication, Restasis as not medically necessary. There is a letter from the carrier to the member dated 01/22/2016 which states in part:
“We have declined on behalf of your plan to provide benefits, in whole or in part, for Restasis Droperette…
…This product is not covered for the indication provided.”
There is a statement on the Physician Certification Experimental/Investigational …show more content…
Patient could greatly benefit from the use of Restasis…
…Patient has dry eye syndrome and would benefit from Restasis.
…No other product other than Restasis has the potential to optimize the ocular surface in my patient.”
Final External Review Decision:
The carrier’s decision to deny coverage for the requested prescription medication, Restasis as experimental/investigational for the treatment of this member’s condition was not …show more content…
According to the Physician Certification form dated 04/22/2016, the member has a diagnosis of bilateral keratoconjunctivitis sicca (dry eye syndrome) and artificial tears alone have not been sufficient therapy.
Restasis® is a topical immunomodulator indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca.
Per the Plan language, coverage of Restasis is provided for dry eye conditions due to ocular inflammation associated with keratoconjunctivitis sicca (KCS), dry eye conditions due to systemic inflammatory diseases (e.g., Sjögren syndrome, rheumatoid arthritis [RA], systemic lupus erythematosus [SLE]), and dry eye conditions due to ocular surface diseases (e.g., ocular rosacea, atopic keratoconjunctivitis, acute corneal graft rejection, blepharitis, herpetic stromal keratitis, conjunctival graft versus host disease [GVHD].
The carrier’s decision to deny coverage for the requested prescription medication, Restasis as experimental/investigational for the treatment of this member’s condition was not
The carrier has denied coverage of the prescription medication, Restasis as not medically necessary. There is a letter from the carrier to the member dated 01/22/2016 which states in part:
“We have declined on behalf of your plan to provide benefits, in whole or in part, for Restasis Droperette…
…This product is not covered for the indication provided.”
There is a statement on the Physician Certification Experimental/Investigational …show more content…
Patient could greatly benefit from the use of Restasis…
…Patient has dry eye syndrome and would benefit from Restasis.
…No other product other than Restasis has the potential to optimize the ocular surface in my patient.”
Final External Review Decision:
The carrier’s decision to deny coverage for the requested prescription medication, Restasis as experimental/investigational for the treatment of this member’s condition was not …show more content…
According to the Physician Certification form dated 04/22/2016, the member has a diagnosis of bilateral keratoconjunctivitis sicca (dry eye syndrome) and artificial tears alone have not been sufficient therapy.
Restasis® is a topical immunomodulator indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca.
Per the Plan language, coverage of Restasis is provided for dry eye conditions due to ocular inflammation associated with keratoconjunctivitis sicca (KCS), dry eye conditions due to systemic inflammatory diseases (e.g., Sjögren syndrome, rheumatoid arthritis [RA], systemic lupus erythematosus [SLE]), and dry eye conditions due to ocular surface diseases (e.g., ocular rosacea, atopic keratoconjunctivitis, acute corneal graft rejection, blepharitis, herpetic stromal keratitis, conjunctival graft versus host disease [GVHD].
The carrier’s decision to deny coverage for the requested prescription medication, Restasis as experimental/investigational for the treatment of this member’s condition was not