Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The patient is a 22-year old female who has diagnoses of bipolar disorder type I with recent manic with psychotic features, currently depressed,  posttraumatic stress disorder, concern for borderline personality disorder, eating disorder and gender dysphoria.  The records indicated the patient was unresponsive to current treatment.  The patient has had trials of antidepressants in combination with augmenting atypical antipsychotics and other agents without significant benefit.  The patient has a history of four past psychiatric hospitalizations. The provider indicated that the purpose of the testing was to identify potential challenges in metabolizing future antidepressant and/or augmentation agents. The provider progress note dated 11/13/15 was included for review. This progress note indicated the genetic testing results. The patient may have reduced enzyme activity compared to persons with the normal phenotype.  She was noted to be heterozygous for serotonin transporter and this was associated with increased time to respond to selective serotonin reuptake inhibitors (SSRI) medications.  The treatment plan included avoiding antidepressant (SSRI) medications due to her diagnosis of bipolar disorder, establishing   psychological therapeutic care with emphasis on coping and safety promoting skills with consideration of dialectic behavior therapy due to a concern for possible borderline personality disorder, prescription of Prazosin due to nightmares, continuation of lurasidone due to her bipolar disorder and continuation of lamotrigine for mood stabilization. The patient has requested reimbursement for the genetic testing performed on 11/10/15. The Health Insurer denied the request for reimbursement and reported that the services at issue were investigational for the evaluation of this patients medical condition.  The evidence based data does support the use of pharmacogenomic testing in cases like this one. In a review by Kirchheiner and colleagues, they noted that there is still considerable controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or adverse events is prevented, to an extent of any practical importance in clinical practice. Instead, there is strong evidence based support for medication and psychotherapy in this patients case. It is not clear that medication and psychotherapy have been used in an evidence based manner for treatment of this patient.  The literature recommends further prospective validation in the routine application of pharmacogenetic dose adjustment. Additionally, while the record notes that this patient continues to struggle with symptoms of her mental illness, the supplied materials do not indicate that the patient has failed evidence based psychotherapy trials. The documentation provided does not indicate that the patient has failed medication trials of adequate dose and duration. It is also unclear whether the patient has attempted psychotherapy. The supplied materials do not indicate what the problematic symptoms are and do not indicate what symptoms are not under control or what the patients functional status was at the time of the testing.  Further, one of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy, which can occur on an outpatient basis. Yet, the record does not indicate that this has been done in this patients case. Accordingly, the current evidence based literature indicates that the patient could have potentially benefited from psychotherapy for her behavioral health conditions.  For these reasons, the genetic testing performed on 11/10/15 was not likely to have been more beneficial than the standard available options for the evaluation of this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.