Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fibromyalgia.
Treatment: Cymbalta 30 milligrams (mg) OR (oral) CPEP (Capsule Delayed Release Particles).
The insurer denied coverage for Cymbalta 30 milligrams (mg) OR CPEP.
The denial is overturned.

This adult female has depression, anxiety, fibromyalgia, and chronic pain and was prescribed brand name Cymbalta to target these symptoms. It was reported that she had efficacy with nerve pain while on this medication and had side effects of nausea and vomiting with the generic Cymbalta which is Duloxetine. 
  
The insurer denied coverage for brand name Cymbalta 30 mg per day to target depression, anxiety, and fibromyalgia stating that the provider did not explain why other formulary medications including Mirtazepine, Sertraline, Citalopram, Escitalopram, Fluoxetine, Paroxetine, Amitriptyline, or Nortriptyline would not be appropriate for the patient's condition. 

This patient had reports of depression, anxiety, fibromyalgia, and chronic pain so Cymbalta was considered medically necessary treatment for her multiple conditions. The other formulary medications including Mirtazepine, Sertraline, Citalopram, Escitalopram, Fluoxetine, Paroxetine, Amitriptyline, or Nortriptyline would not be able to treat all of those conditions. They would only treat depression and anxiety, so Cymbalta was considered appropriate for the patient's condition. The patient was unable to tolerate the generic Cymbalta (Duloxetine) as she had reports of side effects including nausea and vomiting and it was not effective. The brand name Cymbalta reportedly was effective in treating the patient's multiple conditions of depression, anxiety, fibromyalgia, and chronic pain and she had no reported side effects, so Cymbalta brand name was considered medically necessary for this patient's conditions. 

According to an article by Wohlreich & Watkin titled "Role of Duloxetine in the Treatment of Depression and Associated Painful Symptoms" (1), Duloxetine is an antidepressant that effectively treats painful physical symptoms in depressed patients. It also states that alleviating physical symptoms in depressed patients such as pain significantly increases the probability of achieving remissions. Approximately 50 percent of Duloxetine's antidepressant effect on pain in depressed patients occurs independently of changes in core emotional symptoms of depression. It also states that results obtained in clinical trials of Duloxetine support direct effects on pain and demonstrates the importance of effective treatment of painful physical symptoms associated with depression. The article notes that this is compelling evidence for the treatment of pain and depression. No other antidepressant is FDA (Food and Drug Administration) approved for the treatment of both depression and musculoskeletal pain. 

This FDA approved medication for depression, anxiety, fibromyalgia, and chronic pain was a unique medication with all of those indications of use. 

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 the Cymbalta 30 milligrams (mg) OR CPEP is overturned. Medical Necessity is substantiated.