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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous ketamine treatment (once every two weeks). At issue is whether the requested intravenous ketamine treatments (once every two weeks) to treat the enrollees mental health or substance use disorder are medically necessary 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.The submitted documentation supports the medical necessity of the requested medication. Current medical literature supports the use of ketamine in this clinical setting. Wilkinson and colleagues note ketamine rapidly reduced suicidal thoughts, within one day and for up to one week in depressed patients with suicidal ideation. Sanacora and colleagues note that several studies now provide evidence of ketamine hydrochlorides ability to produce rapid and robust antidepressant effects in patients with mood and anxiety disorders that were previously resistant to treatment. In this case, given that the patient has failed a number of antidepressant treatments and reportedly responded to ketamine infusions, the requested medication is medically indicated. Based on the records, the requested intravenous ketamine treatments (once every two weeks) are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the intravenous ketamine treatments (once every two weeks) are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested intravenous ketamine treatments (once every two weeks) are 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. Therefore, intravenous ketamine treatments (once every two weeks) are medically necessary as defined in Health and Safety code section 1374(a)(3)(A).Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. 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.