Pharmacogenetic Testing denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested out of network mental health services on an emergent or urgent basis. Findings: The physician reviewer found that review of the submitted documentation reveals this patient’s developmental task of identity formation was compromised by a serious mood disorder. Upon presentation, the patient was depressed and unable to self-soothe. He had multiple static risk factors. His progressive clinical deterioration demanded intensive specialty services, and the combination of both psychotherapy and pharmacotherapy represented a trusted combination that was reasonably expected to improve the patient’s condition and prevent a more serious episode of illness.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for a gene test. She has a history of bipolar depression and has experienced panic attacks, anxiety and episodes of mania. She has been treated with lithium, BuSpar, Seroquel and Abilify, but she experienced side effects and anxiety despite the medications. Her provider ordered genetic testing in order to determine the correct medication and dosage for the enrollee’s condition. The enrollee reports that since the testing and medication adjustments she feels she has achieved long-term stabilization of her condition. Pharmacogenetic testing, also called pharmacogenomics, or pharmacogenetics, was developed to evaluate a person’s potential response to drug therapy based on their genetic makeup. It is sometimes recommended for those who appear to be refractory to their drug regimen.

Nature of Statutory Criteria/Case Summary: An enrollee has requested testing for evaluation of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the testing was not medically necessary for evaluation of the patient’s medical condition. In general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individual’s genetic organization, may become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness. However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application. The American Psychiatric Association (APA) practice guidelines do not recommend genetic testing for cases involving routine medication management.

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