Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viibryd. At issue in this case is whether Viibryd is medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. According to a study, vilazodone (Viibryd) is a combined serotonin reuptake inhibitor and 5-HT1A partial agonist and is an approved therapy for the treatment of Major Depressive Disorder (MDD.) The study also states vilazodone is an effective agent for treating MDD in adults and is generally well tolerated. In this case, the patient has been stable on his current psychiatric regimen for refractory, recurrent MDD for several years now. The patient was stabilized without needing electroconvulsive therapy (ECT) or other treatments for refractory depression. It would be destabilizing and not medically recommended to have the patient discontinue a medication regimen that has allowed him reprieve from his depressive symptoms for the last couple years. Given the refractory nature of the patients depressive symptoms, Viibryd is a reasonable option in this clinical setting. Viibryd is in accordance with the generally accepted standards of mental health and substance use disorder care. The requested medication is clinically appropriate in terms of type, frequency, extent, site, and duration. Additionally, Viibryd is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. For these reasons, Viibryd is medically necessary for treatment of this patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A). Final Result: The reviewer determined the requested medication is medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 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.