Anxiety Rx denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for a three month refill of Effexor 150mg, a three month refill of Seroquel 200mg, individual psychotherapy every two weeks, and monthly visits with a psychiatrist. The enrollee has chronic recurrent depression and anxiety, exacerbated by recent stressors. Her symptoms were relatively well-managed until she had a panic attack in March. Subsequently, her medications were changed and her mood worsened causing her to have panic attacks every week. She started having suicidal ideations since she was getting two weeks supplies of medication, and wanted more. She was scheduled for a psychiatry follow-up for a second opinion, and larger supplies of Effexor XR and Seroquel but was unable to follow through with the appointment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage Aptiom and Banzel.Banzel and Aptiom are both approved by the U.S. Food and Drug Administration for the management of epilepsy. It is estimated that 20 to 40 percent of seizure patients have drug-resistant epilepsy. Trials of additional anti-seizure medications can be of benefit in individuals with drug-resistant epilepsy. According to Gilioli and colleagues, sequential drug trials can produce remission rates estimated at four to six percent per year, or a cumulative rate of 14 to 20 percent. According to Neligan and colleagues, 29 percent of patients with drug-resistant epilepsy in which drug changes were made had 50 to 99 percent improvement in seizure frequency. In this case, the patient has tried and failed multiple anti-epileptic medications.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Xanax and/or Ambien. Typically, the initial approach to treating anxiety disorders centers on therapies that target the monoamine system. The primary options for treatment consist of pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (such as sertraline) and serotonin-norepinephrine reuptake inhibitors (like venlafaxine extended-release) are the preferred pharmacological treatments for generalized anxiety disorder, social anxiety disorder, and panic disorder.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with anxiety disorder, insomnia, and obstructive sleep apnea. Per the records, he has been treated with Xanax, Ambien, trazodone and temazepam. The provider noted the patient had been seen by a psychiatrist in the past, but he did not want to take the medication that was recommended. The patient requested a refill of Xanax for daily use due to anxiety. The provider noted that daily use of Xanax was not an appropriate treatment for the management of anxiety. The provider prescribed Xanax 0.5 mg with a quantity of 10 to use as needed. The patient requested Xanax for chronic insomnia. He has requested authorization and coverage for Xanax 0.5 mg tablets, 30 tablets per 30 days. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient.

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 Anxiety Rx, then check the rights and deadlines that apply to your plan.