Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Insomnia
Treatment: Zolpidem TART ER 12.5 MG TAB (Zolpidem Tartrate Extended Release 12.5 milligram tablet)
The insurer denied the Zolpidem TART ER 12.5 MG TAB (Zolpidem Tartrate Extended Release 12.5 milligram tablet)
The denial is upheld

The patient is a male who was reported to have been diagnosed with insomnia. The patient's provider is requesting the use of the non-formulary medication, zolpidem ER (extended release) 12.5 mg (milligrams) tablet for treatment of the patient's symptoms. The requested medication was noted to have been previously denied coverage by the health plan, as there was no indication that the patient had failed to respond to at least 2 preferred formulary alternatives or had contraindications or adverse effects to other formulary alternatives available for treatment of insomnia.

Additional clinical information provided indicates that the patient was previously treated with zolpidem 10 mg (milligrams) daily at bedtime. There was no indication of the patient was treated with any other medications for treatment of insomnia. An appeal letter provided by the treating provider indicates that the patient was previously treated with zolpidem 10 mg (milligrams), which was reported to have been no longer effective. The provider indicates that the patient was recommended extended-release zolpidem. He was reported to have a diagnosis of bipolar disorder and insomnia. No other clinical documentation was provided to indicate the patient's ongoing symptoms, history of treatment including medications or response to any previous treatment.

No, the requested zolpidem ER (extended release) 12.5 mg (milligrams) tablet is not medically necessary.
The patient is a 40-year-old male who was reported to have been diagnosed with insomnia. The patient's provider is requesting the use of the nonformulary medication, zolpidem ER (extended release) 12.5 mg (milligrams) tablet for treatment of the patient's symptoms. Medical information provided indicates that the patient was previously treated with zolpidem 10 mg (milligrams) tablet. There was no indication that the patient was treated with any other medications for treatment of insomnia. There was no indication of the patient was unable to be treated with any of the other formulary alternatives available for treatment of insomnia.

There is no evidence in current peer reviewed, evidence based medical literature to indicate that other covered formulary drugs would be ineffective or would not be as effective as the requested non-formulary drug (zolpidem ER [extended release] 12.5 mg [milligrams] tablet). There are several covered formulary medications that may be utilized for treatment of chronic insomnia (1-4). There is no evidence in medical literature to suggest that external delay zolpidem would be more effective than the health plan's preferred medications for treatment of chronic insomnia.

There is no evidence in current peer reviewed, evidence based medical literature to indicate that the covered formulary drugs would have more adverse effects than the requested non-formulary drug (zolpidem ER [extended release] 12.5 mg [milligrams] tablet). Common adverse effects of zolpidem include drowsiness, dizziness, abnormal dreams, and mood symptoms, which are similar to other medications for insomnia (5-6).

Therefore, given the above, the requested zolpidem ER (extended release) 12.5 mg (milligrams) tablet was not found to be exclusively medically necessary for this patient.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient is a male who was reported to have been diagnosed with insomnia. The patient's provider is requesting the use of the nonformulary medication, zolpidem ER (extended release) 12.5 mg (milligrams) tablet for treatment of the patient's symptoms. Medical information provided indicates that the patient was previously treated with zolpidem 10 mg (milligrams) tablet. There was no indication that the patient was treated with any other medications for treatment of insomnia. There was no indication of the patient was unable to be treated with any of the other formulary alternatives available for treatment of insomnia. There is no evidence in current medical literature that the requested medication (zolpidem ER [extended release] 12.5 mg [milligrams] tablet) would be more effective or would have fewer side effects than other covered medications that are available for treatment of the patient's symptoms related to insomnia. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.