The carrier has denied coverage of Gralise ER 600mg tablets as experimental and/or investigational and not medically necessary. There is a letter from the carrier to the member dated 03/21/2016, which states in part:
“AFTER REVIEW OF THE CLINICAL INFORMATION YOUR DOCTOR SUBMITTED, IT HAS BEEN DETERMINED THAT THE INDICATION RELATED TO USE OF THIS MEDICATION IS NOT FDA APPROVED PER GRALISE PACKAGE INSERT. GRALISE IS ONLY INDICATED FOR THE MANAGEMENT OF POSTHERPETIC NEURALGIA (PHN). YOUR DOCTOR DID NOT INDICATE YOU ARE USING THIS IS NOT ABLE TO BE APPROVED. PLEASE DISCUSS ALTERNATIVES WITH YOUR DOCTOR, SUCH AS GABAPENTIN.”
There is a preauthorization form dated 03/23/2016, which states in part:
“Neurotin - fluid retention, swelling… Flexeril is …show more content…
On the Prior Authorization request form dated 03/23/2016, Dr. Johnson writes, “Patient stable on Gralise since 6/2014” and lists the diagnosis of restless legs syndrome (RLS). However, it is important to note that there are no symptoms for diagnosis of RLS documented anywhere else in the records submitted for review.
In the documentation from July 2015, it is noted that the member was being treated with Gralise 1200 mg daily, Zanaflex, Norco, Ambien, butalbital, lorazepam, lithium, topiramate, Remicade, plaquenil, Botox, and other drugs. The same diagnoses are listed, including RLS. However, again there are no symptoms of RLS documented. In fact, the sentences of this note that refer to Gralise are under the heading titled