Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety. 
Treatment Xanax (brand). 

The insurer denied coverage for Xanax (brand). 

The denial is overturned. 

This female reportedly was taking brand name Xanax 0.25 mg (milligrams) three times per day (TID) for anxiety symptoms and reported efficacy and no adverse effects. It was reported that she had taken generic Alprazolam even as high as 0.75 mg TID and had decreased efficacy with worsened anxiety and also had side effects including nausea, headache, and stomach aches. The patient reportedly had anxiety symptoms and a diagnosis of generalized anxiety disorder, major depressive disorder, panic disorder, and post-traumatic stress disorder (PTSD). She also reportedly was taking brand name Paxil as she had side effects from the generic Paroxetine including gastrointestinal upset. It was reported also that she failed all other selective serotonin reuptake inhibitor (SSRI) generic medications. 
  
The insurer denied coverage for brand name Xanax stating that a generic Alprazolam was available and as effective for treatment. 
  
According to Focus: The Lifelong Journal in Psychiatry: Anxiety Disorders Summer Volume II (2) Number 3, pages 346-357, it states that for patients with generalized anxiety disorder cognitive behavioral therapy, pharmacotherapy, and other psychotherapies were not only indicated but also have been shown to result in reduction of symptoms. The standard pharmacological treatment for generalized anxiety disorder and panic disorder is serotonin reuptake inhibitors and also benzodiazepines. 

This patient reportedly was taking both a serotonin reuptake inhibitor and also a benzodiazepine, but only the brand name Xanax and Paxil were effective in decreasing anxiety significantly and also the only medications without adverse effects. The Food and Drug Administration (FDA) approved maximum dosage for Xanax is 4 mg per day. This patient reportedly responded well to 0.5 mg TID which is 1.5 mg per day, so the dosage was within the Food and Drug Administration (FDA) approved dosing for Xanax. For a subset of patients, there are indications that specific psychotropic medications could have a greater likelihood of response and tolerability based on clinical characteristics such as psychiatric comorbidities, medical comorbidities that could be exacerbated by psychotropic medication side effects, or family member history of response to a particular psychotropic agent. While these clinical characteristics might guide a clinician to select a particular type of first-line drug treatment, for many patients the best treatment match is not clear, and treatment decision making is a process of "trial and error." 

In this case this patient responded to brand name Xanax 0.5 mg TID mg and had an improvement in her symptoms and no medication side effects reported. The generic medication that was recommended by the insurer, Alprazolam, was tried and was reportedly not effective resulting in worsened anxiety and also resulted in adverse medication side effects including nausea, headache, and stomach aches. The patient responded best to the brand name Xanax and did not respond to the generic equivalent Alprazolam. This patient reportedly had a good clinical response to the brand name benzodiazepine Xanax and did not respond well to the generic equivalent Alprazolam including the one manufactured by Greenstone as suggested by the insurer. As a result, the recommendation is to reverse the previous decision and approve coverage for brand name Xanax for this patient. 

The health care plan did not act reasonably with sound medical judgment or in the best interests of the patient. The medical records provided enough specific evidence to support that she required this brand name Xanax. 

The insurer's denial of coverage for Xanax (brand) 0.5MG OR TABS (tablets) for the treatment of anxiety is overturned. Medical necessity is substantiated.