Depression - Severe denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for inpatient hospitalization services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee’s behavioral health conditions. This patient was admitted to the inpatient unit due to possible suicidal ideation and issues with relationships and inappropriate behaviors on the internet. On an initial evaluation, the patient reported some possible passive suicidal ideation. This passive suicidal ideation appeared to abate after her first day in the hospital. She did not have any active suicidal ideation or plans to harm herself and did not make any attempts to harm herself or others during her hospital stay.

The patient is an 18-year-old female admitted to residential treatment in March 2006 with an increased level of depression and escalating substance abuse. The record indicates she begun to use alcohol at the age of 12 and progressed to daily use between the ages 14 to 16. The patient later used cannabis and began using amphetamine at age 13, initially snorting, then smoking, and finally mixing it with heroin and injecting it in the year prior to admission. She reported daily use of significant quantities of amphetamine and heroine. The patient described herself as “always depressed” and noted seasonal variation in her mood, typically more depressed in the winter months. Her symptoms included irritability, disrupted sleep patterns, low energy, and low self-esteem. The patient often expressed hopelessness and suicidal ideation and claimed to have made several suicide attempts previously.

Where the denial was upheld

Physician 1: The patient is a 37-year-old female with an extensive history of mental illness. She has been diagnosed as having major depression with psychotic features and/or schizoaffective disorder, and has tried numerous psychotropic medications which include Geodon, Wellbutrin, Effexor, Seroquel, Risperdal, Lorazepam, Lamictal, Cymbalta, Celexa, Depakote and Xanax along with electroconvulsive therapy (ECT). According to the patient and her provider, she has had adequate trials of the various treatments. The patient currently has depressed mood, crying spells, anxiety, disturbed sleep, disturbed concentration and feelings of hopelessness/helplessness with suicidal ideation. Her current regimen of medications is not helpful. The patient, as well as her provider, feels that they have exhausted all available treatment alternatives.

Physician 1: The patient is a 55-year-old female with a diagnosis of major depression. She is now seeking vagus nerve stimulation (VNS) therapy for treatment and management of her depression. Her provider reports the patient’s condition has been refractory to psychopharmacological treatment and electroconvulsive therapy (ECT). The Health Plan has denied authorization for VNS therapy on the basis that it is an experimental treatment and therefore a non-covered benefit. The patient is appealing the Health Plan’s denial.To date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research centered and clinically based reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of the established principles of health care practice as of this date for the management of refractory depression.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving depression - severe, then check the rights and deadlines that apply to your plan.