Diagnosis: Skin disorder /Acne
Treatment: pharmacy /prescription drugs
The insurer denied Tretinoin 0.01% EX GEL.
The denial is Upheld in whole .


This is patient with acne. The patient has been treated with BenzaClin, Bactrim, topical Clindamycin, Adapalene .1% gel, Doxycycline, and Minocycline.
No, medical necessity for Tretinoin .01% gel has not been established. The records submitted include an MD note where the patient presented for a skin check. At that time the current medications are listed: Bactrim and Clindamycin/Benzyl Peroxide. There is no history with regards to the efficacy of these medications. The records submitted don't chronicle which medications had been tried and failed. The provider indicates that Minocycline and Doxycycline were tried in 2015 but there are no medical records included for review to document this. The medical records actually reflect that the patient had success with Epiduo Forte, but the medication was not continued. This would not be deemed a failure of treatment. The office note was reviewed and considered. The patient has acne that got worse when the patient ran out of the requested medication tretinoin .01% gel. Regardless, the patient does not have a documented trial and failure with other options. The Tretinoin .01% gel is not medically necessary for this patient.