Spravato denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Spravato (esketamine) Nasal Solution.At issue in this case is whether Spravato (esketamine) Nasal Solution is medically necessary to treat the enrollee’s mental health or substance use disorder as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below? “Medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in term…

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for esketamine (Spravato) nasal spray. This patient carries a documented diagnosis of major depressive disorder, recurrent severe, without psychosis. Moreover, the patient meets the definition of treatment resistant major depressive disorder due to failure of medical therapies including high-dose Paxil 40 mg and Lexapro. He has also had multiple trials of sufficient duration with Wellbutrin. Currently, he is on Viibryd 40 mg daily in addition to Wellbutrin XL 300 mg daily and BuSpar 5 mg three times a day. He is currently on the maximum dose of Viibryd, and has undergone a sufficient trial of medication and Wellbutrin.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Spravato. A government study noted that “Patients with the major depressive disorder who, despite trying at least two antidepressant treatments given at adequate doses for an adequate duration in the current episode, have not responded to treatment are considered to have treatment-resistant depression.” On review of this patient’s records, there is documentation that she has been taking Wellbutrin XL 300 mg. There is no report that the patient was treated with Wellbutrin 450 mg, which would be the next step in treatment if tolerated. The record shows that Rexulti 1 mg daily was recommended, but there is no mention of whether the patient was treated with a higher dose.

The patient has requested authorization and coverage for Spravato. The available records document that this patient has undergone treatment with multiple anti-depressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). However, there is a lack of documented history of treatment with monoamine oxidase inhibitors (MAOI’s), which are recommended for the treatment of patients with treatment-resistant depression (Van den Eynde, et al.). In addition, the provider did not report trials on augmentative agents such as atypical anti-psychotics such as quetiapine, aripiprazole, olanzapine, and risperidone, or other augmentation agents including lithium, thyroid hormone, or mood stabilizers (McIntyre, et al.).

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