Anti-Psychotic denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for esketamine (Spravato) nasal spray. This patient carries a documented diagnosis of major depressive disorder, recurrent severe, without psychosis. Moreover, the patient meets the definition of treatment resistant major depressive disorder due to failure of medical therapies including high-dose Paxil 40 mg and Lexapro. He has also had multiple trials of sufficient duration with Wellbutrin. Currently, he is on Viibryd 40 mg daily in addition to Wellbutrin XL 300 mg daily and BuSpar 5 mg three times a day. He is currently on the maximum dose of Viibryd, and has undergone a sufficient trial of medication and Wellbutrin.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parents of the patient requested authorization and coverage for risperidone and aripiprazole.Risperidone and aripiprazole are currently the only medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of irritability associated with autism spectrum disorder (ASD) in children and adolescents. Further, patients with ASD are frequently treated with multiple medications. Clinical trials have found these medications to be effective in reducing irritability consisting primarily of physical aggression and severe tantrum behaviors, as well as repetitive behaviors in ASD. Risperidone has been approved for ages 5 through 16 years and aripiprazole for ages 6 – through 17.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) risperidone (Risperdal), and (2) inpatient psychiatric hospitalization services for a minimum of 30 days and up to 90 days at a facility that specializes in paranoid schizophrenia with negative affect and bipolar disorder. In treating patients with psychosis, the determination of the antipsychotic and treatment plan should be in a shared decision making model between the patient and the clinical team. In this case, the patient has been noncompliant with and resistant to taking medications. Given that the patient’s current psychiatric treatment team is not recommending treatment with risperidone and the patient’s refusal of medications, the requested medication is not medically indicated.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication oxcarbazepine.Findings: Three out of three physician reviewers found that the requested medication oxcarbazepine is not likely to be more beneficial than any other available standard treatments for the patient’s medical condition.According to the International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder, the anticonvulsants divalproex sodium and carbamazepine have not fared well head-to-head with second-generation antipsychotics (SGAs). The Task Force report noted that in two meta-analyses, treatment effect was less robust with anticonvulsants than with SGAs.

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