Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old male who has a 28-year history of major depression versus bipolar disorder. The patient reports he was previously treated on an outpatient basis at a frequency of every two weeks. The patient prefers more frequent psychiatric sessions and desires ready access to psychiatrists by telephone. Treatment has included a number of medications, most recently Effexor, Abilify, and Neurontin. Furthermore, past treatments have included a very wide range of antidepressants including moclobemide, imipramine, Prozac, Paxil, Celexa, Luvox, and Wellbutrin, both in combination with benzodiazepines as well as with Lithium on occasion. Additionally, the patient has had a vagal nerve stimulator implanted for two years and several rounds of electroconvulsive therapy (ECT). All told, he did not find any of these treatments particularly effective, typically noting anger and regulation of impulse as the two most paramount problems within his depression. The physician who had been administering ECT eventually concluded that the patient was not benefiting from the therapy. The Vagal nerve stimulator was removed after two years due to a similar lack efficacy. Some of the improvement in the patients mood that he has noticed along the way has seemed spontaneous and not clearly related to any medicinal course. The records indicate that although the patient has felt suicidal at points, it has never been with truly serious intent or actual attempts.An intake assessment of 7/13/04 noted the patients judgment as skewed by axis II issues and noted the patients temper was an issue. He was also determined to be suffering from narcissistic traits on axis II assessment. The patient has requested authorization and coverage for sessions with a psychiatrist every two weeks. The Health Plan has determined that the requested frequency of visits is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical records indicates the patient has been tried on a very wide array of medicinal and otherwise somatically directed therapies, all without definitive benefit. As such, it appears his depression is chronic. There is no evidence the patient has had a robust response to any treatment he has received over a period of several years. Further, there is nothing to indicate he is in need of acute level of service with every other week sessions. This is not to say that the patient does not warrant treatment at all, but it is within the purview of his treating physicians to decide just how treatment ought to be approached. Moreover, the failure to respond to conventional treatment after so many years points to character pathology as a most likely consideration, and a confounding factor in responding to conventional treatment for depression. In point of fact, character traits were noted on the 7/13/04 assessment as quite germane. As such, there is no evidence the requested services are likely to result in improvement in the patients condition. Therefore, I have determined that the requested services are not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.