Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand name medication, Lunesta.Findings: According to a study, Insomnia disorder is defined in the International Classification of Sleep Disorders, Third Edition, as a complaint of trouble initiating or maintaining sleep which is associated with daytime consequences and is not attributable to environmental circumstances or inadequate opportunity to sleep. The disorder is identified as chronic when it has persisted for at least three months at a frequency of at least three times per week. The study further states, Chronic insomnia is associated with numerous adverse effects on function, health, and quality of life. Epidemiologic studies demonstrate marked impairment in functional status among those with chronic insomnia. In a clinical practice guideline for the management of chronic insomnia, another study states that the American College of Physicians (ACP) recommended that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. The study also states that the American Academy of Sleep Medicine (AASM) clinical practice guidelines for the pharmacological treatment of chronic insomnia in adults recommends that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. The study indicates, Overall, the benefits of eszopiclone 2 mg and 3 mg were judged to be greater than the potential harms. Based on clinical judgment, AASM  determined that the majority of well-informed patients would use eszopiclone over no treatment. This judgment is based on the evidence of improvement in sleep latency, total sleep time, sleep efficiency and sleep quality, coupled with its low potential for adverse events. Moreover, the AASM guideline states, The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. In this case, the patient has been diagnosed with insomnia. The patient is reported to be better controlled with brand name Lunesta than on the generic version of this medication. Based on the ACP and AASM clinical practice guidelines, a shared-decision approach and individual circumstances should guide the specific care and treatment that is best for the patient. Therefore, the requested brand name medication, Lunesta, is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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.