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

The patient is a 66-year-old female who was diagnosed with depressive disorder, possible somatization disorder, chronic fatigue syndrome, interstitial cystitis, and irritable bowel syndrome. She has been treated in outpatient therapy for 10 years by a lay therapist and via medications from a psychiatrist for the past two years. The patient has had varying dosages of Celexa, Klonopin, and trazodone from her psychiatrist with varying degrees of success in lessening her anxiety and depression. The patient has requested coverage for continued outpatient therapy sessions. Records submitted by the patients psychiatrist reveal the following: 12/25/02: Affect brighter. Depression decreased. Going out more. Drove a few times. Involved in meal preparation. Walking without walker or wheelchair. Sleep good. Appetite increased. Continue present medications, (Celexa 20mg, Klonopin 0.5mg), decrease trazodone 100mg.1/28/03: Condition continued to worsen on Celexa 10mg. Increased Celexa to 20mg on 12/31/02. Feeling better since increased dose. Almost back to condition prior to dose decrease. Denied feeling depressed. Without significant anxiety. Driving again 1 time per week. Sleep fair.5/9/03: Dealing with multiple stressors: MVA, dental problems, on-going physical pain and other somatic complaints. Complaints of feeling increasingly depressed and anxious. Increase Celexa to 40mg, trazodone to 150mg.10/3/03: Taking Celexa 40mg x 1 month; calmer and less depressed. Coping better. Cut back significantly on most analgesic doses. Sleep fair. Appetite good. Making effort to decrease carbohydrate snacking. Taking care of ADLs, but says she is in bed a lot of the time. Appears stable.12/11/03: Twitching and restless legs had been much decreased over the last two plus months. Now increased again for few days following recent dental work. Denies feeling depressed. Sleep fairgood until a few days ago. Appetite good but also having GI symptomsdiarrhea, hunger-like pains. Functioning well. Appears stable. Celexa 40mg.2/10/04: Mirapex dose increased which has decreased restless legs. Without significant depression. Decreased anxiety. Denies vegetative symptoms. Continue Celexa, trazodone.6/15/04: Taking above medications (Celexa 30mg, trazodone 100mg). Says she is home much of the time, either in bed or watching TV. Multiple somatic complaints. More anxious, increased depression. Sleep decreased5 hours per night. Appetite good, weight increased, increased snacking on carbs. Concentration decreased. Increase Celexa to 40mg, trazodone 150mg.There appears to be no evidence psychotherapy has offered this patient any significant gains in terms of depressive or somatic symptoms. Despite a 10-year course of psychotherapy she has continued to be significantly depressed and somatically stricken, particularly in the past two years. Alternatively, review of some of her psychiatrists notes, as detailed above, indicate variable, but apparently definitive benefit from medications, though the regimen has not deviated from Celexa and trazodone. Thus, it appears medicinal treatment has helped to some extent, admittedly not entirely, and psychotherapy alone was of insignificant benefit (hence the initial referral for medication treatment). To the extent that therapy has been supportive and the patients status has declined in the past two years, further therapy of this sort ought not to be authorized. There are other medications from which to draw to treat the patients depressive illness if Celexa and trazodone are incompletely effective. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.