Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Ambien 25mg.At issue in this case is whether the Ambien is medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Despite thorough review of the literature and U.S. Food and Drug Administration labeling information for Ambien CR and Ambien, there is no indication for short-term and long-term safety with doses above Ambien CR 12.5 mg. It is unclear why Ambien CR 25 mg was prescribed for ten years, since the safety of this regimen is questionable. Additionally, since the patient is also prescribed fluoxetine, the half-life of the Ambien CR is actually prolonged, leading to worsening daytime sedation and residual effects of the medication, which heightens safety concerns further. According to researchers and colleagues, pharmacotherapy is one of two major approaches to treatment, the alternative being cognitive behavioral therapies for insomnia, which is already identified as a standard of treatment. Although non-sedative/hypnotic medications have been tried with this patient, cognitive behavioral therapy for insomnia as well as other sedative-hypnotic options have not been attempted. Additionally, the patients metabolism of these other agents might differ and allow for safer prescribing of the medications for insomnia than with such a high dose of Ambien CR. For these reasons, Ambien 25 mg is not medically necessary for treatment of the patients medical condition. Specifically, Ambien 25 mg is not in accordance with generally accepted standards of mental health and substance use disorder care. Further, Ambien 25 mg is not clinically appropriate in terms of extent or dosage strength. Ambien 25 mg is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.