Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for evaluation of the enrollees behavioral health conditions. Findings:  Three physician reviewers found that the record also included the diagnosis of bipolarity.  The patient was previously prescribed Lamictal, Trileptal, Wellbutrin, Celexa and Prozac, and most recently lorazepam and zolpidem.  However, at the time of the disputed service, the patient was prescribed alprazolam, melatonin and omega-3 fatty acid supplementation.   Genetic testing of methylenetetrahydrofolate reductase was ordered by the primary care provider to assess for a genetic mutation.  The Health Plan has denied reimbursement for genetic testing performed on 9/09/16.  Per the Health Plan, the services at issue were investigational for the evaluation of this patient. In general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well 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.  Trusted psychiatric reference texts do not recommend genetic testing for cases involving routine medication management.  Further, the American Psychiatric Association (APA) did not endorse such testing in a recent official statement or its most current clinical practice guidelines.  In this patients case, the clinical documentation failed to support the necessity of genetic testing.  First, the patients illness burden was steeped in anxiety, not affective symptomatology.  She was not prescribed a mood enhancing medication, while the diagnosis of bipolar illness was uncertain.  There was no evidence of psychiatric consultation or elaboration of the reported non-pharmacologic interventions, such as psychotherapy, biofeedback and toastmasters.  In the absence of a psychiatric evaluation and review of the specific type, setting and duration of psychotherapies, or, the selection, dosing, length of previous psychotropic medication trials and relevant associated circumstances, it cannot be inferred that the patient had exhausted standard treatments available to treat her condition.  The records do not document that the disputed gene test yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity.  Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.