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

The patient is a 54-year-old female with a long-standing history of major depression, bulimia nervosa, and post-traumatic stress disorder. She reports feelings of hopelessness, being overwhelmed, passive suicidal ideation, reduced energy, poor self-images, low motivation, and self-destructive behavior of cutting her left arm several times per week. The patient has been treated in outpatient care by both a psychiatrist as well as a therapist; the exact orientation of the psychotherapy is unclear. However, the patient has been treated with Geodon, Buspar, Prozac, Wellbutrin, Effexor, Paxil, Zoloft, Celexa, and Elavil in the past, apparently all without any sustained improvement or with intolerable side effects. She has been treated with Lexapro, Neurontin, and Seroquel for about the past two years and is currently requesting vagus nerve stimulation (VNS) therapy, refusing a course of electro-convulsive therapy (ECT) due to her concern about memory deficits.Review of her psychiatrists notes from the past two years points to the patient as having a variable degree of depression and anxiety, given to constant cutting on her left arm as some means of emotional release yet no formalized suicidal acts. She has experienced some periods of overspending, having maxed out credit cards, and rather few neurovegetative symptoms. On one occasion, when she was not able to cut on herself, she intentionally slammed her finger in a car door. The patient was otherwise noted as often having good energy and libido, good appetite and normal sleep but was anxious and obsessive and compulsive overall. She was also often concerned about being overweight yet had no binging or purging episodes during this two year time period. Her antidepressant regimen was not changed at all during this time.At issue in this case is whether VNS therapy is medically necessary for treatment of the patients medical condition.Given the transient depressive symptoms, but largely preserved functional ability inclusive of being able to enjoy herself with friends, it is surprising that the patient has been deemed treatment refractory. Evidently, the patients medication regimen has remained the same for two years. In light of this, it is not clear why the notion that the patient is refractory to treatment has now been invoked. Taken purely at face value from a medicinal standpoint, however, a course of a monoamine oxidase inhibitor (MAOI) might have been considered. Additionally, given the patients spending sprees and seasonal variation in mood, a bipolar spectrum illness could have been considered with a proportionate change in medication course. At the same time, there is a question as to what is really being treated, i.e., the patients depression, such as it is, or her underlying personality disorder (not that the two are particularly separable). That the patient has been cutting on herself for years, minus more formalized suicidal intent, is indicative of borderline personality disorder. Because of the personality disorder, it would not be reasonable to expect her chagrin to disappear entirely with any medicinal route at any point. And ironically, though ECT has been considered for her, it is actually not indicated both because the patient is not that ill from a purely depressive standpoint as well as due to her underlying personality disorder, which bodes poorly for response to ECT. Given that ECT is not indicated for this patient, VNS is clearly not either. Benefits from VNS are modest, at best. All told, I find that the patient is not likely to benefit from VNS and it is not medically indicated for treatment of her behavioral health problems.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.