This is a patient who has a history of chronic psychotic disorder best characterized as bipolar I mood disorder with the most recent episode manic with psychotic features, and a clinical course with prior acute psychotic episodes in the context of mood disturbance and medication non-adherence and poor insight. The patient has failed to respond to olanzapine quetiapine, fluphenazine and long-acting haloperidol due to a lack of effectiveness and/or adverse effect in the context of the non-adherence to medication regimen.
The health plan's determination is overturned.
In this case scenario, the patient has demonstrated a clinical response to Abilify Maintena, as noted in the clinical summary. The patient has a history of medication non-adherence and non-compliance with treatment for her chronic psychotic and mood disorder resulting acute episodes of psychosis and mania requiring inpatient level treatment. Thus, the requested benefit of Abilify Maintena at the current dosage is reasonable and in the patient's best interest in keeping with prevailing standards of medical practice, especially in view of the fact that she was able to tolerate the initial treatment with oral formulation while being monitored for compliance in the hospital setting.