Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Generalized Anxiety Disorder

Treatment Trintellix

The insurer denied coverage for Trintellix

The denial is overturned

This patient had anxiety symptoms including anxious mood, excessive worrying, and physical symptoms of anxiety including nausea and vomiting. She had a diagnosis of Generalized Anxiety Disorder. She also had a history of depressive symptoms and past opioid use. She was taking Suboxone. She had been in treatment with mental health provider. She had tried many medications for anxiety including Sertraline, Escitalopram, Citalopram, Fluoxetine, Paroxetine, Duloxetine, Venlafaxine, Desvenlafaxine, Mirtazepine, and Bupropion. She also tried Clonazepam, Alprazolam, Hydroxyzine, and Depakote. The request was for Trintelluix (Vortioxetine) 5 mg (milligrams) per day.
    
This reviewer disagreed with the decision to deny coverage for Trintellix (Vortioxetine) as this patient tried multiple anti-anxiety medications with reported sustained efficacy or with adverse effects. She tried 5 serotonin reuptake inhibitors including Sertraline, Escitalopram, Citalopram, Fluoxetine, Paroxetine, 3 serotonin-norepinephrine reuptake inhibitors including Duloxetine, Venlafaxine, Desvenlafaxine, Mirtazepine which has a unique mechanism of action and increases serotonin and norepinephrine, and also tried a histamine blocker in Hydroxyzine, and 2 benzodiazepines in Clonazepam and Alprazolam. She tried multiple classes of anti-anxiety medications without efficacy. She also reportedly tried Bupropion which is an antidepressant with mechanism of action of being a dopamine norepinephrine reuptake inhibitor. Trintellix, which is also Vortioxetine, is a serotonin modulator as it is a serotonin reuptake inhibitor, norepinephrine transporter blockers. Although it is Food and Drug Administration (FDA) approved for adults with Major Depressive Disorder with a maximum FDA approved dosage of 20 mg per day, some medical literature supports the use of Trintellix (Vortioxetine) to treat anxiety disorder. 

According to "Vortioxetine Treatment for Anxiety Disorder: A Meta Analysis Study" by Yee, Ng, Seng, and Loh, it stated that Vortioxetine was overall superior to placebo in terms of mean change from baseline using the Hamilton Anxiety Scale and had good safety and tolerability. The conclusion stated that it supported the use of Vortioxetine for anxiety disorder. This patient had tried so many different FDA approved types of anti-anxiety medications including every serotonin reuptake inhibitors that was FDA approved for the treatment of anxiety and every serotonin-norepinephrine reuptake inhibitor also FDA approved for anxiety as well as other classes of medications used to treat anxiety, and did not have  sustained efficacy or  tolerability, so trying this unique class of medication, Trintellix (Vortioxetine), was considered to be an appropriate treatment and appeared to be medically necessary treatment then. Because of its unique mechanism of action as it is a serotonin reuptake inhibitor, norepinephrine transporter blocker, a 5HT1A (serotonin receptor) and 5HTIB (serotonin receptor) partial agonist, a 5HT1D, 5HT3A and 5HT7 (serotonin receptor) receptor antagonist, this medication was considered to be a medication to try to treat anxiety symptoms. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Trintellix is reversed. Medical Necessity is substantiated.