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

The patient is a 44-year-old female with a past history of depression, anxiety, and chronic pain secondary to reflex sympathetic dystrophy. She was treated in the past with Zoloft and Pamelor. Recently, she was being treated with Effexor 450mg with a good response. It was noted she was able to return to work after being off on disability for months due to the extent of her depression. However, she was felt to have continued somnolence secondary to the Effexor and when an attempt was made to lower the dose of the Effexor, her anxiety markedly increased and her mood diminished. Provigil was then added to the patients regimen and significant improvement in her alertness and functioning was noted. Use of amphetamine was believed to be contraindicated because of a past history of substance abuse. She had been in recovery for substance abuse for ten years. Chart notes of the patients physician indicate the patients dose of Effexor was increased to 450mg in May 2004, in addition to Geodon 40mg. The patient was noted to be feeling spacey and still fatigued on her follow-up evaluation in June 2004. She was felt to still be fatigued on her visit of 7/12/04, though with some improvement in mood and no other perceived side effects from Effexor. The patient was then started on Provigil 200mg per day and upon her return visit on 7/26/04, it was noted the patients mood was up. The notes further indicate that the patient was less anxious, driving more, more alert on Provigil with some improvement in sleep, more active, and more social. On 8/2/04, the patient was noted as coping with stress better, sleeping the same, appetite is the same, no new symptoms. Notes from 9/17/04 indicate the patients mood appeared normal and alert. At that time no change in the patients medication course was recommended. Finally, on 11/12/04, the patient was noted as feeling much better, mood is up, with no further mention of fatigue. A request has been made for authorization for continued use of Provigil. The Health Plan has denied this request on the basis that Provigil is not medically necessary for treatment of the patients medical condition. Though the patients records do not substantiate a diagnosis of refractory depression per se, Provigil was prescribed as an adjunct to Effexor due to excess daytime fatigue secondary to Effexor. The patient appears to have had an excellent response to Effexor. The articles cited above demonstrate there is support in the medical literature for use of Provigil to combat daytime fatigue secondary to an antidepressant. The addition of Provigil to the patients regimen was a medically sound decision. The patient was able to return to work after months off on disability. Switching the patient to another antidepressant at this time places the patient at risk of becoming depressed yet again, losing what level of functionality she has recovered. Use of Provigil in this clinical setting is medically reasonable and appropriate and should be continued. Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.