Provigil denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 58-year-old woman with a history of fibromyalgia with associated chronic fatigue syndrome and depression since the early 1990’s. The patient has been prescribed many medications including Trazadone, Nortriptyline, Flexeril, Celexa, Zoloft, Ultram, Voltaren, etodolac, and Neurontin. Treatment with these medications provided the patient with significant pain relief but resulted in minimal increase in her energy level. Since initiating Provigil in June 2003 the patient has noted marked improvement in her energy level and quality of life. She has also been able to stop use of Neurontin while taking Provigil. The patient has requested authorization and coverage for continued treatment with Provigil.

The patient is a 44-year-old female with a past history of depression, anxiety, and chronic pain secondary to reflex sympathetic dystrophy. She was treated in the past with Zoloft and Pamelor. Recently, she was being treated with Effexor 450mg with a good response. It was noted she was able to return to work after being off on disability for months due to the extent of her depression. However, she was felt to have continued somnolence secondary to the Effexor and when an attempt was made to lower the dose of the Effexor, her anxiety markedly increased and her mood diminished. Provigil was then added to the patient’s regimen and significant improvement in her alertness and functioning was noted. Use of amphetamine was believed to be contraindicated because of a past history of substance abuse. She had been in recovery for substance abuse for ten years.

Where the denial was upheld

The patient is a 59-year-old female with a longstanding history of depression that began in her college years. She was initially evaluated by her most recent psychiatrist in August 2003. At the time of the evaluation, the patient was receiving a combined regimen of Geodon 20mg twice a day, Lexapro 10mg a day, Wellbutrin SR 100mg twice a day, Zyprexa 10mg a day, Klonopin 1mg twice a day, Ativan 2mg at time of sleep, and phentermine 37.5mg a day. At her August 2003 evaluation, the patient noted insomnia, chronic rumination, absent mindedness, and procrastination, and could remember two of three unrelated items after three minutes, was only able to perform three serial subtractions, could not spell the word ‘world’ backwards, was only able to repeat four digits in reverse order, but immediately recalled 14 of 15 items of a detailed paragraph.

The patient is a 55-year-old male with headaches and daytime somnolence. His provider noted an increase in the patient’s headaches and fatigue approximately six weeks after stopping Provigil. Elavil has been prescribed to treat the patient’s headaches and there is a note from the provider suggesting the patient may be taking Celexa as well. The patient’s provider indicates that Provigil has been prescribed to “to keep (the patient) awake and more focused during the day.” The patient’s request for authorization of Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.The FDA approved indications for Provigil include narcolepsy syndrome, sleepiness due to obstructive sleep apnea, and sleepiness due to shift work sleep 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 Provigil, then check the rights and deadlines that apply to your plan.