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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychotropic gene testing for evaluation of the enrollees behavioral health condition. Findings:  The 3 physician reviewers found that The psychotropic gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the American Psychiatric Association (APA) clinical practice guidelines In time, genetic testing may help guide selection or dosing of antidepressants {which are first-line treatments for anxiety disorders}, but data are currently insufficient to justify the cost of such tests.  In this case, the clinical documentation submitted for review failed to support the genetic testing at issue. The records show that the patient was taking clonazepam for episodic anxiety which was well-tolerated and efficacious. Further, the clonazepam was conservatively dosed. Thus, it does not appear that the patient had failed the benzodiazepine, which represents a standard therapy for anxiety. Also, pro-serotonergic medications are first-line treatments for anxiousness. The patient had a brief trial of one selective serotonin reuptake inhibitor, sertraline, in 2013 that lasted less than three weeks and was discontinued against medical advice. The trial was inadequate based on the duration of treatment and dosage of the medicine. Further, assuming no adverse drug response, a typical serotonin-based medication needs up to six weeks of daily administration to effect clinical positivism.  Moreover, the documentation submitted for review did not include a psychiatric evaluation or review of the specific type, setting and duration of psychotherapies, which represents another first-line intervention in the treatment of anxiety disorders. Considering the peer-reviewed literature and current practice standards, it is not possible to assert with any degree of confidence 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.  Thus, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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: Physician reviewer number one is board certified in psychiatry and is actively practicing. The reviewer is an expert 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.Physician reviewer number two is board certified in psychiatry and is actively practicing. The reviewer is an expert 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.Physician reviewer number three is board certified in psychiatry and is actively practicing. The reviewer is an expert 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.