Anti-Depressants 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 Viibryd. At issue in this case is whether Viibryd is medically necessary to treat the patient’s mental health or substance use disorder 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; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not p…

A 33-year-old female enrollee has requested Neurontin 300mg, Ambien 10mg, Lamictal 150mg, prazosin 1mg, clonazepam .5mg, alprazolam .5mg, fluoxetine 20mg and bupropion 15mg for the enrollees bipolar disorder, obsessive-compulsive disorder and panic disorder. Findings: The physician reviewer found that per the submitted documentation, medication changes were made frequently, and there is no documentation regarding degree of compliance. This patient has been diagnosed with bipolar disorder, and Lamictal is an evidence-based treatment for this condition according to the American Psychiatric Association practice guidelines. The patient seems to have been fairly stable throughout her treatment with her current provider, and she appears to have been on this medication the entire time.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intravenous ketamine infusion therapy services. Medical literatures describe ketamine as an uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist that has emerged as a novel therapy for treatment-resistant depression, noting that an (S)-ketamine nasal spray has been approved for use in treatment-resistant depression, in conjunction with an oral antidepressant, in the United States and Europe. However, intravenous ketamine is not currently approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression and remains an off-label treatment for depression. The evidence base surrounding the use of intravenous ketamine in unipolar and bipolar depression has been growing, demonstrating rapid and robust antidepressant effects within hours of administration.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Seroquel 600 mg daily, clonazepam 1 mg twice daily, modafinil 200 mg daily and Belsomra 20 mg (frequency unknown) for treatment of the enrollee’s behavioral health conditions.Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications. Although appropriate patient-centric care may ultimately arrive at rather uncommon medication regimens, there is no longitudinal evidence in the medical record of systematic progression through standard pharmacologic therapies, applied in conjunction with evidence-based non-pharmacologic interventions, to arrive at the rather atypical regimen requested by the patient. In terms of indication, the patient has been diagnosed with unspecified anxiety disorder.

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 Anti-Depressants, then check the rights and deadlines that apply to your plan.