Treatment-resistant Depression denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly therapy.At issue is whether the requested weekly therapy is medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. If weekly therapy is upheld as not medically necessary to treat the enrollee’s condition, is therapy every other week medically necessary to treat the enrollee’s condition, as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below? If therapy every other week is upheld as not medically necessary to treat the enrollee’s condition, is therapy every three weeks medically necessary to treat the enrollee’s condition, as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below?

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous ketamine treatment (once every two weeks). At issue is whether the requested intravenous ketamine treatments (once every two weeks) to treat the enrollee’s mental health or substance use disorder are medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below. “Medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care;…

Where the denial was upheld

Physician 1: The patient is a 32-year-old female with a diagnosis of treatment resistant depression. She has had multiple hospitalizations for the treatment of depression and pseudotumor cerebri. The patient may also suffer from borderline personality disorder and episodes of self-destructive behavior and frequent suicidal ideation are noted. Several medications are mentioned, but only Cymbalta and Geodon are included in the current treatment regimen. It is not clear from the record why Geodon was prescribed. The patient has requested authorization and coverage for vagus nerve stimulation (VNS) therapy. The Health Plan has denied this request on the basis that there is insufficient evidence of its efficacy at this time.A review of the submitted clinical information does not indicate whether there has been a sufficient trial of medications, including MAOIs.

Physician 1: The clinical documentation concerns a 53-year-old male who has a history of depression that he states has occurred over the last 21 years. He has had multiple pharmacological trials but reports that he still has symptoms and has been unable to pursue his profession as a veterinarian. His primary symptom appears to be his memory loss. The patient gives an example in his letter of not being able to recognize his old patients. His treating psychiatrist recommended neuropsychiatric testing but the submitted documentation does not contain the results of a MMSE or formal neuropsychological testing. The patient also reported a tremor and some possible weakness in his extremity.

A diagnosis does not by itself establish treatment intensity. See the separate record for residential, PHP, IOP, inpatient, and withdrawal-management denials: behavioral-health level-of-care evidence guide.

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 treatment-resistant depression, then check the rights and deadlines that apply to your plan.