Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Insomnia.
Treatment:  Belsomra.

The insurer denied Belsomra.  The denial is upheld.

The patient is an adult female, who was reported to have been diagnosed with bipolar disorder (F31.0), anxiety disorder (F41.0) and attention deficit hyperactivity disorder (F90.9). The patient's provider is requesting the use of the non-formulary medication, Belsomra (suvorexant) 5 milligram (mg) tablet, 1 tablet by mouth daily at bedtime, #30 for 30 days for treatment of symptoms related to insomnia. The requested medication (Belsomra) was noted to have been previously denied, as there was no indication that the patient had failed to respond to other preferred medications or had contraindications or adverse effects to the preferred formulary medications available for treatment of insomnia. The preferred formulary alternatives indicated include extended-release zolpidem, eszopiclone, zaleplon and ramelteon. The patient was noted to have been seen for a clinical encounter 4 months ago. Diagnoses indicated include bipolar disorder, anxiety disorder and attention deficit hyperactivity disorder. The patient was noted to have been treated with psychotropic medications including lurasidone, 
alprazolam, duloxetine, zolpidem and trazodone. Previous clinical documentation indicates that the provider had discontinued zolpidem and started the patient on Belsomra (suvorexant). She was noted to have been continued on trazodone and alprazolam. A pharmacy paid claims report indicates that the patient was treated with psychotropic medications including duloxetine, alprazolam, trazodone, lurasidone, hydroxyzine, zolpidem, and doxepin.

The proposed treatment (Belsomra, 5 milligram tablet) was not found to be medically necessary.

The patient is an adult female who was reported to have been diagnosed with bipolar disorder (F31.0), anxiety disorder (F41.0) and attention deficit hyperactivity disorder (F90.9). The patient's provider is requesting the use of the non-formulary medication, Belsomra (suvorexant) 5 milligram tablet, 1 tablet by mouth daily at bedtime, #30 for 30 days for treatment of symptoms related to insomnia. There is no evidence in current peer-reviewed, evidence based medical literature to indicate that the requested non-formulary drug (Belsomra) would be more effective than other formulary drugs for treatment of symptoms related to insomnia. Belsomra is a medication approved for insomnia that works by blocking the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R, which is thought to suppress the central drive for wakefulness. This is a unique mechanism of action, unlike other medications used to treat insomnia (3, 4, 5). However, there are several medications that may be utilized for treatment of symptoms related to insomnia, including over-the-counter sleep promoting agents, ramelteon, zolpidem extended release, zaleplon and eszopiclone which would be expected to be at least as effective as Belsomra in this patient (1, 2). In addition, there are several other medications that may be utilized off label for treatment of insomnia. There is no evidence in current peer-reviewed, evidence based medical literature to indicate that the requested non-formulary drug (Belsomra) would have less adverse effects than other formulary drugs available for treatment of insomnia. Common adverse effects of Belsomra include drowsiness, dizziness, abnormal dreams, and mood symptoms, which are similar to other medications for insomnia (6-8). The requested non-formulary drug, Belsomra, would not be expected to have less adverse effects than all other formulary drugs. Therefore, the proposed treatment with the non-formulary medication (Belsomra 5 milligram tablet) was not found to be exclusively medically necessary.