Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression; Anxiety.
Treatment: Viibryd.
The insurer denied the Viibryd.
The denial is upheld.

The patient is an adult male. He is diagnosed with a depressive disorder and comorbid anxiety disorder. He was started on Viibryd (vilazodone) titrated to 20 mg (milligrams) daily. The patient had been treated previously with two other antidepressants, mirtazapine and escitalopram, which failed to provide a clinical response or remission. The patient was switched from escitalopram to Viibryd by his treating clinician. There were no reported symptoms of mania, thought disorder, psychosis or severe cognitive impairment in this case, and there were no other psychiatric co-morbidities or current diagnoses of co-occurring substance use disorders. Other medications include continued use of mirtazapine 45 mg (milligrams) daily, buspirone 10 mg (milligrams) tid (three times daily), and prn (as needed) use of clonazepam and hydroxyzine at clinically appropriate dosages. The patient's PHQ 9 (patient health questionnaire) and GAD 7 (Generalised Anxiety Disorder Assessment) scales scores were 11 and 15 respectively, indicating persistent symptoms of depression and anxiety.

The patient's prescribing physician is requesting health plan coverage for Viibryd. The health plan has denied coverage for Viibryd on the basis of the plan formulary preferences and plan policy that does not endorse or recognize the effective use of samples as a legitimate reason for coverage. The health plan indicates that the current use of Viibryd is likely samples, which are not acceptable under the health plan. The health plan indicates that there is no rationale why formulary alternatives (preferences) are not appropriate.

The prescribing physician indicates that the patient has tried and failed an SSRI (selective serotonin reuptake inhibitor) and to prescribe another SSRI (selective serotonin reuptake inhibitor) is not reasonable. Moreover, the prescribing physician indicates that Viibryd at the current dose of 20 mg (milligrams) daily is helping. Additionally, the appeal indicates that the patient has tried and failed other medications including Vistaril, Klonpin, Ativan and Buspar, as well as escitalopram and mirtazapine.

No, the requested treatment with Viibryd is not medically necessary for this patient.
The prescribing physician indicates that the patient has tried and failed an SSRI (selective serotonin reuptake inhibitor) and to prescribe another SSRI (selective serotonin reuptake inhibitor) is not reasonable. Moreover, the prescribing physician indicates that Viibryd at the current dose of 20 mg (milligrams) daily is helping. Additionally, the appeal indicates that the patient has tried and failed other medications including Vistaril, Klonpin, Ativan and Buspar, as well as escitalopram and mirtazapine.

However, there is no documented evidence that the health plan's preferences would not be effective in the treatment of this patient's depression and anxiety. The health plan reason for the denial effectively argues that there is no rationale why formulary alternatives (preferences) are not appropriate. Comparative effectiveness or similar efficacy in the treatment of depressive disorder is expected with these alternative agents, despite the appeal reasons noted above.

Comparative effectiveness or similar efficacy in the treatment of depressive disorder is expected with the health plan's alternative agents, despite the appeal reasons noted above.