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

Physician 1:  The patient is a 27-year-old female who states that she has had problems with anxiety and panic episodes since adolescence. She has presented herself to the Emergency Department on two occasions for panic attacks manifested by dizziness, palpitations and difficulty concentrating. The patient has had trials of Celexa and Xanax but no information is available concerning the effect of these medications on her anxiety and panic episodes. She was referred by her primary care provider for a consultation with an integrative medicine specialist in May 2006. The specialist recommended a treatment plan including yoga, hypnosis and biofeedback and made a referral to a psychotherapist as well. It is not known from the record if the patient pursued psychotherapy. The patients request for authorization of hypnosis and biofeedback was denied by the Health Plan citing the experimental nature of the therapies.A generalized anxiety disorder beginning in adolescence typically has both a biological and environmental component. Anxiety with panic episodes is frequently found in families and is considered a familial trait. Anxiety may also be related to unresolved issues or conflicts amenable to psychotherapy. The biological component of anxiety associated with panic episodes often requires medication. A combination of SSRIs and a short acting benzodiazepine is the standard of care for this condition. The use of hypnosis is not considered a standard of care in the psychiatric community. It is not clear from the record that standard treatment modalities proven to be effective for anxiety and panic episodes have been fully explored. Therefore, I have determined that the requested services are 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.Physician 2:  The patient is a 27-year-old female with an apparent history of anxiety disorder and panic attacks. The record indicates she initially refused a referral to a psychiatrist but was later referred to a psychologist. The patient has been treated with Celexa 20mg per day and Xanax 0.25mg as needed up to three times per day. According to her providers notes, the Xanax is used sparingly. There are two documented panic attacks in the record. The patients provider recommended pharmacologic intervention and psychotherapy as well as the requested modalities of hypnosis and biofeedback. The patient is requesting authorization for treatment of her anxiety with hypnosis and biofeedback. The Health Plan considers these therapies experimental/investigational and denied coverage.A search of the peer-reviewed literature found no support for the use of biofeedback or hypnosis as a primary treatment for an anxiety disorder. There is no data available to support the efficacy of the proposed interventions. The patient was referred for psychotherapy in May 2006, and may yet derive a benefit from that approach to treatment of her anxiety disorder. Based on current clinical evidence, I have determined that the requested services are 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.Physician 3:  The patient is a 27-year-old female with a history of generalized anxiety disorder and panic attacks. She apparently has a preference for treatment with biofeedback and hypnosis as compared to referral to a psychiatrist and psychopharmacological treatment. The patient would like to move forward with the preferred services and has submitted a request for authorization. The Health Plan has denied the requested biofeedback and hypnosis on the basis that these therapies have not been shown to be efficacious in the treatment of anxiety disorders. There is insufficient evidence in the peer-reviewed literature to support the effectiveness of biofeedback and hypnosis in the treatment of the patients anxiety disorder.  It has not been shown that the generally accepted approaches to treatment of this condition have been ineffective for her. Accordingly, I have determined the requested services are not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. The Health Plans denial should be upheld.