Lexapro denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Lexapro for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the FDA provides medication dose recommendations based on scientific data. The interpretation and application of these recommendations falls upon clinicians working directly with the patient population. This process allows for consideration of additional factors, such as physician experience, emerging treatment trends and clinical issues unique to individual cases, in the delivery of evidence-based, patient-centric care. As such, it is not uncommon for providers to dose medications in excess of FDA recommendations. Systematic medication titration is a core element of the art of medical practice and a key component to patient-centered care.

The patient has requested authorization and coverage for brand name medication, Lexapro 20 mg tablet. According to the records provided for review, this patient has been stable on brand name Lexapro for over 10 years for the maintenance of her major depressive disorder (MDD). The American Psychiatric Association (APA) guidelines indicate that patients treated for an uncomplicated MDD who exhibit a satisfactory response to an antidepressant medication should continue to receive a full therapeutic dose of that agent after achieving remission in order to prevent the recurrence of mood symptoms. Generic antidepressants are the first-line of pharmacological treatment of MDD. However, this patient’s records document failure of two prior antidepressant trials, long-term stabilization on brand name Lexapro, and the inability to tolerate the generic version of Lexapro.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Lexapro for treatment of the enrollee’s depression and bipolar disorder. Findings: The physician reviewer found that Escitalopram is a potent and highly selective serotonin reuptake inhibitor that acts by binding directly to the serotonin transporter. Escitalopram was first approved by the U.S. Food and Drug Administration (FDA) in 2002 for treatment of major depressive disorder, and a year later for generalized anxiety disorder. As noted by researchers, bioequivalence testing “ensures that the generic product performs the same as its respective brand-name product. This standard applies to all generic drugs, whether immediate or controlled release”.

A 68-year-old female enrollee has requested Lexapro 10mg for treatment of her depression. Findings: The physician reviewer found that this patient has a history of depression. She reports a failure of two medications in the past as well as intolerable side effects from another medication. The combination of one of the failed medications and Lexapro has improved her depressive symptoms. Her Health Plan requires that she fail two one-month trials of SSRI medications, one of them being Celexa, prior to a trial of Lexapro. This patient has not had even one failure of a pure SSRI medication reported in the past. Regarding the efficacy of Lexapro, there are clinical trials that suggest that Lexapro may have a faster onset of antidepressant efficacy and modest superiority in the treatment of the severely depressed.

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