Xanax denials in California external review

What the reviewers wrote

Where the denial was overturned

A 35-year-old female enrollee requested Norco 10/325, 1-2 every 4-6 hours; Xanax 0.1 mg twice daily; and Flexeril 10 mg for medical treatment of her medical conditions. Findings: The physician reviewer found that a portion of the requested medications are medically necessary for treatment of the patient’s medical condition. According to the documentation submitted for review, the patient is being treated for headaches and neck pain radiating into the left upper extremity. She appears to have a combination of myofascial pain and rotator cuff impingement. In this clinical setting, the request for Norco 10/325, 1-2 every 4-6 hours and Xanax 0.1 mg twice daily are not medically necessary for treatment of the patient’s medical condition. The continued use of Norco carries the risk of medication overuse as well as rebound headache.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall XR 15 mg and/or Xanax 0.5 mg #15. The records provided for review document that this patient has diagnoses of autism, GAD, and ADHD. The patient has reportedly benefited from treatment with Adderall XR for ADHD and infrequent use of Xanax for breakthrough anxiety symptoms. On review of the peer-reviewed medical literature, this patient’s request for continued treatment with Adderall XR and Xanax is supported as medically necessary.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Xanax and/or Ambien. Typically, the initial approach to treating anxiety disorders centers on therapies that target the monoamine system. The primary options for treatment consist of pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (such as sertraline) and serotonin-norepinephrine reuptake inhibitors (like venlafaxine extended-release) are the preferred pharmacological treatments for generalized anxiety disorder, social anxiety disorder, and panic disorder.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with anxiety disorder, insomnia, and obstructive sleep apnea. Per the records, he has been treated with Xanax, Ambien, trazodone and temazepam. The provider noted the patient had been seen by a psychiatrist in the past, but he did not want to take the medication that was recommended. The patient requested a refill of Xanax for daily use due to anxiety. The provider noted that daily use of Xanax was not an appropriate treatment for the management of anxiety. The provider prescribed Xanax 0.5 mg with a quantity of 10 to use as needed. The patient requested Xanax for chronic insomnia. He has requested authorization and coverage for Xanax 0.5 mg tablets, 30 tablets per 30 days. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient.

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