Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The patient is a 22-year old female who has been diagnosed with bipolar I disorder, posttraumatic stress disorder, unspecified eating disorder, gender dysphoria and rule out borderline personality disorder. The patient has history of four psychiatric hospitalizations and pharmacotherapy. As part of a comprehensive evaluation, the patient completed genetic testing on 11/10/15. The patient is requesting reimbursement for the services at issue. The Health Insurer denied reimbursement for the genetic testing performed on 11/10/15 on the basis that the services at issue were investigational for the evaluation of this patients medical condition. In general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  Additionally, a publication from the Patel research group represents one of many promising findings, but the recommendation for future hypothesis driven confirmatory genetic studies in independent cohorts as well as testing for mechanistic interactions relevant of bipolar disorder pathophysiology, illustrates the lack of clinical reasonableness for testing at this point. In this patients case, standard pharmacotherapeutic strategies for bipolar disorder had yet to be optimized at the time of the genetic testing.  In general, the use of antidepressants in bipolar illness is at the very least controversial and may in fact exacerbate the affective impairment stemming from bipolarity.  This patient had multiple antidepressant trials which may have been counterproductive.  Further, the records do not show that this patient had been treated with other mood stabilizing medications, most notably lithium which remains a first line option for all domains of bipolar disorder. Finally, there was no mention of electroconvulsive therapy which represents another highly effective treatment for bipolar disorder.  Additionally, regarding this particular clinical scenario, there was no case specific information detailing the longitudinal history, functional impairment or contemporaneous psychosocial stressors.  Lastly, the specific type, setting and outcome of evidence based psychotherapies and social cultural spiritual community activities were not presented.  As such, considering the relevant peer reviewed literature and current practice standards, it is impossible 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   genotype testing performed on 11/10/15 was not likely to have been more effective than the alternative methods for the evaluation of this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.