A review of the records reveals the member to be an adult female with a birth date of 04/08/1962. The member has a diagnosis of herpes simplex virus 2. The member’s treating provider, Christina Chen, MD recommended the member be treated with Acyclovir 5% ointment 30/30.
The carrier has denied coverage of Acyclovir 5% ointment 30/30 as not medically necessary. There is a letter from the carrier to the member dated 04/22/2016 which states in part:
“According to our policy, the medical necessity criteria for Acyclovir 5% ointment 30/30 have not been met in this case. You do not meet the criteria because it has not been demonstrated or documented that you have had previous treatment within the past12 months with, or shown intolerance to, oral acyclovir. Therefore, based on the policy and provided clinical documentation, the medical necessity criteria have not been met in this case. …show more content…
I desperately need the topical cream/ointment in conjunction with the oral medication to provide some relief.”
Final External Review Decision:
The carrier’s decision in denying coverage for the requested Acyclovir 5% ointment 30/30 was not
The carrier has denied coverage of Acyclovir 5% ointment 30/30 as not medically necessary. There is a letter from the carrier to the member dated 04/22/2016 which states in part:
“According to our policy, the medical necessity criteria for Acyclovir 5% ointment 30/30 have not been met in this case. You do not meet the criteria because it has not been demonstrated or documented that you have had previous treatment within the past12 months with, or shown intolerance to, oral acyclovir. Therefore, based on the policy and provided clinical documentation, the medical necessity criteria have not been met in this case. …show more content…
I desperately need the topical cream/ointment in conjunction with the oral medication to provide some relief.”
Final External Review Decision:
The carrier’s decision in denying coverage for the requested Acyclovir 5% ointment 30/30 was not