Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety. 
Treatment: Trintellix 10 milligram (mg) oral tablets. 
The insurer denied Trintellix 10 mg oral tablets. 
The health plan's determination is upheld. 

The patient is a female who was diagnosed with an unspecified depressive disorder and was prescribed Trintellix at a dose of 10 mg daily. There is a comorbid condition reported in this case which is an unspecified anxiety disorder. 

The health plan denied the request for coverage of the 10 mg tablet of Trintellix on the basis of the plan guidelines indicating that the request for Trintellix 10 mg is not a covered benefit according to the Pharmacy Benefit Plan and indicating that Vilazodone (Viibryd) is available on formulary as a covered alternative. The denial notes that the mechanism of action of Vilazodone is similar to Trintellix and that the patient is not currently prescribed Trintellix but the submitted information does indicate that Trintellix was previously approved and then the patient was switched to Viibryd (vilazodone). The denial also indicates that the approved formulary alternative, Viibryd, is also approved for treatment of her anxiety disorder, as well as her depressive disorder. 

The prescribing physician indicated that the patient has failed to respond to Wellbutrin, Buspirone and Zoloft and that the patient does not respond to selective serotonin reuptake inhibitors (SSRI's). The appeal indicates that to try another SSRI would only delay any improvement which "could cause serious adverse effects." 

The health plan documents were reviewed, as well as the case summary and progress note, and appeal documents, and correspondence from the health plan and prescribing clinician. Pharmacy records were reviewed, as submitted. This review is New York (NY) State mandated in consideration of instruction for a medical necessity review. 

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. 

The requested health service/treatment of Trintellix 10 mg oral tablets is not medically necessary for this patient. 

There are substance use disorders diagnosed in this case including marijuana with occasional use, and a history of stimulant use disorder with cocaine and methamphetamine use. The patient has chronic medical conditions that includes right knee pain and migraines. 

Documentation indicates moderately severe symptoms of depression and mild to moderate symptoms of anxiety with a Patient Health Questionnaire-9 (PHQ-9) scale score of 17 and a Generalized Anxiety Disorder Assessment (GAD 7) scale score of 10. The submitted information indicates the use of Trazodone and Alprazolam for insomnia and anxiety, as well as use of Mobic for chronic pain. 

There is no evidence that the formulary alternative, Viibryd, would be ineffective or result in tolerability problems. As the denial determination indicates, the mechanism of action of Viibryd (Vilazodone) is similar to Trintellix and is therefore a reasonable alternative which is covered under the plan.

The health plan's determination of medical necessity is upheld. These answers are consistent with the published practice guideline recommendations and the scientific literature, referenced below, and is consistent with New York State instructions for this review.