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

Physician 1This patient is a 47-year-old female with a history of recurrent major depression with a seasonal affective component. She has been treated in outpatient therapy with a variety of antidepressants, antipsychotics, and mood stabilizers, including Abilify, Zyprexa, risperidone, Seroquel, Tegretol, Lamictal, Trazodone, Serzone, Klonopin, Effexor, and Wellbutrin. The first four medications were thought to have led to some depersonalization and therefore were discontinued. The submitted notes indicate that between 4/3/03 to 1/19/04, the patient was treated initially with Trileptal, followed by Lexapro and Wellbutrin, both at modest doses, then just Lexapro alone, and finally back to Lexapro and Wellbutrin, again at modest doses. She was noted to be largely depression free, though with the overlay of seasonal dip in mood. It was therefore felt that rather than add to her list of medications, light box phototherapy would be prescribed. Along the way, some of the patients mood variation was thought to be decompensation of anxiety and depression related to psychosocial stresses. As of 1/19/04, the patient was noted to be doing fairly well with an improvement in her mood.  The patient had not received any phototherapy by that point. Though the diagnosis of bipolar disorder was considered for this patient, particularly given some of her activation with Wellbutrin in addition to the seasonal variation of her moods, she has yet to receive a concerted trial of Lithium without antidepressants. In addition, although there appears to be a veritable seasonal component to her moods, some of her problems appear to be related to psychosocial stresses, such as the behavior of her daughter. Finally, the medical literature does not compellingly differentiate light box phototherapy from placebo response. Thus, standard treatment such as Lithium and psychotherapy are likely to be more beneficial for the patient than unproven light box phototherapy.Based upon the information set forth above, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2The patient is a 47-year-old woman with chronic recurrent major depressive disorder. Her condition has not been relieved by a wide variety of selective serotonin reuptake inhibitors (SSRIs) and other antidepressant medications. There is a documented seasonal component to the patients disorder. A request has been made for light box phototherapy. The Health Plan has denied authorization for light box phototherapy indicating it is considered experimental for treatment of the patients disorder.There is sufficient evidence-based literature to support a trial of light box phototherapy for this patient with a long history of depression. Despite the use of a wide array of SSRIs and antidepressants the patient continues to be symptomatic. Thus, the patients depression appears to be refractive to medication treatment. It is medically reasonable for the patient to undergo a trial of phototherapy given her lack of response to conservative therapy. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3The patient is a 47-year-old woman who has a history of recurrent major depression with a seasonal pattern. The patient has been on many medications without significant improvement in her condition. After a recent exacerbation of the patients depressive symptoms the patients provider recommended light box phototherapy. The Health Plan has denied authorization for light box phototherapy on the basis that it is considered investigational for treatment of the patients depression. The patient has had poor/incomplete responses to traditional pharmacology. However, there is no reason to expect any further improvement in her clinical condition with an unproven treatment that has had quite variable response patterns. Additionally, the patients Axis II diagnosis of cluster B characteristics further decreases the chances of a successful outcome with phototherapy. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.