Modafinil denials in California external review

What the reviewers wrote

Where the denial was overturned

A 32-year-old female has requested past and future coverage for residential treatment, as well as coverage for modafinil (Provigil) 200mg, for treatment of her pain disorder with psychological factors and medical conditions. Findings: The physician reviewer found that based on review of the available records, RTC level of care from the date at issue and forward was and is medically necessary. This patient has a complex presentation and history that requires treatment of multiple chronic medical problems, all of which are inter-related and must be treated together. The medical record indicates that this patient was labile and not in control of her own behavior for more than a few hours per day. Whenever she perceived any type of stress or was not able to have her own way, she began to decompensate. The complex interplay among her problems could not be handled in an outpatient setting.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil 200 mg 45 tablets.Medical literature indicates that modafinil may be an effective alternative to stimulants in the treatment of hypersomnia in patients with bipolar disorder. A study conducted by Frye and colleagues concluded that adjunctive modafinil at doses of 100-200 mg a day may improve depressive symptoms in patients with bipolar disorder.In this case, the submitted medical records indicate that the patient has had hypersomnia for years. She is noted to have struggled with this condition and has seen many specialists in order to maximize her medication treatment for this condition. Medical recommendations include continuation of modafinil, and the literature supports use of the medication for bipolar disorder as well as hypersomnia.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for modafinil tablets. Idiopathic hypersomnia is a central disorder of hypersomnolence. A diagnosis of idiopathic hypersomnia requires all of the following: daily periods of irrepressible need to sleep, or daytime lapses into drowsiness or sleep, that have occurred for at least three months; lack of cataplexy; polysomnography and multiple sleep latency test (MSLT) findings do not support a diagnosis of narcolepsy type 1 or 2; the presence of a MSLT finding indicating a mean sleep latency of less than or equal to eight minutes and/or total 24-hour sleep time is greater than or equal to 660 minutes, typically 12 to 14 hours, as measured by either 24-hour polysomnography that is performed after remediation of any chronic sleep deprivation or by wrist actigraphy in association with a sleep log, av…

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