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

The patient is a 59-year-old female with a longstanding history of depression that began in her college years. She was initially evaluated by her most recent psychiatrist in August 2003. At the time of the evaluation, the patient was receiving a combined regimen of Geodon 20mg twice a day, Lexapro 10mg a day, Wellbutrin SR 100mg twice a day, Zyprexa 10mg a day, Klonopin 1mg twice a day, Ativan 2mg at time of sleep, and phentermine 37.5mg a day. At her August 2003 evaluation, the patient noted insomnia, chronic rumination, absent mindedness, and procrastination, and could remember two of three unrelated items after three minutes, was only able to perform three serial subtractions, could not spell the word world backwards, was only able to repeat four digits in reverse order, but immediately recalled 14 of 15 items of a detailed paragraph. She was thereafter thought to have likely concurrent neuropathy and her operative diagnoses on Axis I included adverse effects of medication not otherwise specified, anxiety disorder resulting from neuromedical condition associated with tachycardia, depressive disorder not otherwise specified, and attention deficit not otherwise specified. She then received an EEG, which showed diffusely low absolute voltage as well as alpha band deficiency and beta excess. The beta-mean frequency was also felt to be fast, no other quantification of deficiency, excess, fast, or neuropathology was offered. However, this was all felt to point to a correlation with response to a beta-blocker and then a stimulant such as Provigil and possibly a MAOI.Treatment since the initial evaluation has included a very varying regimen of medications such as Provigil, Lopressor, Lorazepam, Clonazepam, Wellbutrin, Lamictal, Dexedrine, Diazepam, Adderall, Risperdal, Parnate, and Phentermine. For the most part, these have been prescribed concurrently, for example, Parnate, Provigil, Risperdal, Clonazepam, Lorazepam, and Lopressor together, with dosages of most homeopathic, except for the Provigil, which she has received at doses up to 200 mg three times a day. Her response to the myriad of combinations has been quite variable, some of its ostensibly correlated with EEG reading. For example, at her 8/15/03 visit, her EEG data showed marked improvement from baseline. At the same time, the patient reported that she did not have much energy and was sleeping a great a deal and was having bad headaches. It should also be noted that the patients medications have often been started and stopped within weeks of initiation, and sometimes within days of such. The patient is now seeking authorization for Provigil.Based upon the information provided, the patient does not have a consolidated, operative diagnosis, but more so a myriad of vaguely defined diagnoses mostly listed as not otherwise specified. Some of the patients initially considered diagnoses such as anxiety disorder due to neuromedical condition associated with tachycardia or attention deficit not otherwise specified are not only vague but are not supported by the patients records. For example, the patient s history provides no evidence that she has attention deficit disorder. In addition, there is no evidence the patient has a neuromedical condition. There is no basis for relating a neuromedical condition to the patients initial cognitive deficits or EEG findings. Cognitive deficits abound in mood disorders in general and the patients EEG findings are highly nonspecific. Furthermore, the patients initial EEG did not demonstrate excessive delta and theta activity nor was it diffusely slow as stated by the patients psychiatrist. Rather, the EEG showed low voltage and beta access, but nothing more anomalous. Also, although the patient had noted periods of hyperphagia and her father was noted as impulsive and alcohol dependent, there is no evidence that bipolar disorder has been considered.From a treatment standpoint, the use of EEG findings to guide a patients prescription for diagnoses such as major depression is highly questionable and has not been substantiated as a common practice. Moreover, the patients history of switching between various combinations of medications appears to be too varied and too short with no trial of any one agent extending beyond a few weeks. Therefore, it is very difficult to determine what medications have been beneficial for this patient. Based upon the lack of a clear diagnosis and the patients varied medication history, there is no indication that Provigil is medically necessary for this patient. Therefore, I have determined that the Health Plans denial should be upheld.