Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Narcolepsy

Treatment: Modafinil 100 mg (milligram) tablet for a date yet to be determined and filled at a network pharmacy

The insurer denied coverage for Modafinil 100 mg (milligram) tablet for a date yet to be determined and filled at a network pharmacy

The denial is overturned

This patient reportedly was being prescribed Modafinil 100 milligrams (mg) per day for treatment of narcolepsy. It was reported that the patient was taking this for 10 years with efficacy. Notes from the provider reported that there were no difficulties with narcolepsy currently. It also reported stable mood, organized thoughts, denial of hallucinations, suicidal or homicidal ideation, good concentration, intact judgment, and good insight. The patient reportedly had diagnoses of attention deficit hyperactivity disorder (ADHD)-combined presentation in addition to narcolepsy. It was recommended that Guanfacine be added for focus. Therapy and medication management was recommended for alleviation of symptoms. It was reported that the patient had taken Prozac, Concerta, Adderall, and Strattera. 

The insurer denied coverage for Modafinil 100 mg per day stating that the prior authorization criteria was not met. The criteria for age being 18 or older and the diagnosis for narcolepsy was met but the other criteria of confirmation by certain test results was not met. They stated that there was no documentation confirming the diagnosis by multiple sleep latency test (MSLT) that shows either a mean sleep latency of less than 8 minutes with evidence of 2 sleep onset rapid eye movement periods (SOREMP's) or at least one SOREMP on MSLT and a SOREMP on the previous overnight polysomnography and absence of catalepsy and exclusion of other causes. They stated that there were no records showing that the patient met that criteria so medical necessity was not met.
  
The reviewer disagrees with the decision to deny coverage for Modafinil 100 mg per day for treatment of narcolepsy as the Food and Drug Administration (FDA) approved Armodafinil (Nuvigil) and Modafinil (Provigil)  for the treatment of shift work sleep disorder, narcolepsy, or excessive sleepiness associated with obstructive sleep apnea. Modafinil was FDA approved for narcolepsy in 1998 and in 2003 it was FDA approved for shift work sleep disorder and obstructive sleep apnea and this patient had a diagnosis of narcolepsy. 

This patient had reports of no difficulties with narcolepsy currently, stable mood and organized thoughts as per notes. If this patient were to stop Modafinil which is an FDA approved medication to treat their sleep disorder diagnosis of narcolepsy, the patient likely would have worsened narcolepsy and sleeping problems which also likely would have worsened their depressive and anxiety symptoms, attention and concentration, and functioning. The patient had comorbid diagnoses of dysthymic disorder in the past and ADHD combined presentation and if the patient's narcolepsy were to reoccur, they likely would have worsened symptoms and functioning. It would not have in the patient's best interest to stop taking Modafinil which is an FDA approved medication for narcolepsy. It did not appear that the insurer acted in the best interest of the patient. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for modafinil 100 milligram (mg) tablet for a date yet to be determined and filled at a network pharmacy is substantiated.