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Type 1: A Case Study

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A review of the records reveals the member to be an adolescent male with a birth date of 06/08/1998. The member has a diagnosis of Type 1 Diabetes Mellitus. The member’s treating provider, Rebecca Fannin, MD has been prescribing the member Novolog 100 unit/ml cartridge. The carrier has denied coverage of Novolog 100 unit/ml cartridge as not medically necessary. There is a letter from the carrier to the member dated 03/23/2016 which states in part: “The medical necessity criteria for coverage have not been met in this case. As a result, we are unable to cover the services and apply the allowable to your deductible. In this case, there is no documentation to show that Brandon has tried and failed Humalog. Additionally, the required step…show more content…
On Saturday, 02/20/2016, we attempted to pick up the prescription, but were told by Walgreen’s that is was denied by Humana. This was our first attempt to purchase this medication since our group (HM Graphics, group # 636872) moved to Humana on 01/01/2016. Neither Humana nor Walgreen’s contacted us about the denial, so by the time we needed to pick up the medication it was too late to resolve the issue with Humana, since the proper department was closed. Our hands were tied and we were forced to purchase the drug at full cost because of the lack of communication. Because our son needed the medication THAT DAY, we paid out of packet for the full cost of $673.00 for the medication. It wasn’t until Monday, 02/22/2016 that we found out that Humana put a Step Therapy requirement on the medication, and since we haven’t purchased the drug through Humana to this point, we had no idea that this would ever be a problem.” Final External Review Decision: The carrier’s decision in denying coverage for the requested prescription Novolog 100 unit/ml cartridge was appropriate. There is insufficient medical record documentation to determine whether Novolog is medically necessary for the treatment of this member’s…show more content…
The member has an approximate 8 year 6 month history of Type 1 Diabetes that is managed with continuous subcutaneous insulin infusion (pump) therapy. There are only a few medical records provided for review. However, a visit note dated in January of 2016 notes that the member is on pump therapy. It does not state which insulin was prescribed at that time. However, pumps typically use a short-acting insulin analog. Per the appeal letter from the member’s father, the member has always been on Novolog and, after they switched insurance plans, it wasn’t until they went to pick up the Novolog from the pharmacy that they learned the medication was denied. Since the member needed it, they paid for the full prescription out-of-pocket (presumably a 3-month supply based on the price and the member’s insulin dose) and are now requesting for retrospective coverage. According to the member’s insurance plan, the preferred short-acting insulin analog of choice is Humalog. They note that Novolog is covered if “the member has had previous treatment, contraindication, or intolerance to Humalog.” It further states that this needs to be documented by filling out a specific form. Per the records submitted, no such documentation of “previous treatment, contraindication, or intolerance to Humalog” had been
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