Diagnosis: Generalized Anxiety Disorder.
Treatment: Trintellix.
The insurer denied the Trintellix.
The determination is overturned.

The patient was diagnosed with generalized anxiety disorder with panic attacks who is prescribed Trintellix (vortioxetine). Trintellix is prescribed in order to address symptoms of generalized anxiety disorder that include hypervigilance, anxious mood, ruminations with excess worry, and generalized symptoms of anxiety as well as frequent panic attacks. The panic attacks are characterized as severe and occurring in clusters with feelings of dread and cardio-respiratory symptoms. There is no substance use disorder or psychiatric comorbidity in this case.
The patient has failed prior treatments with multiple antidepressant medications including selective serotonin reuptake inhibitors [SSRIs] (fluoxetine, sertraline and citalopram), duloxetine, bupropion and mirtazapine. Trintellix was started at 10 milligrams (mg) switching from citalopram. The health plan denied the Trintellix indicating that formulary medications are available and have not been tried.
The health plan documents, as well as case a summary/progress note and correspondence from the health plan and prescribing physician were reviewed. The health plan's formulary, prior authorization criteria and prescription drug coverage language requiring step therapy were reviewed as submitted along with plan guidelines and the Certificate of Coverage.
At issue is the medical necessity of Trintellix (vortioxetine) 10 milligrams (mg) daily.

The requested health service/treatment of Trintellix 10 mg tab is medically necessary for this patient considering the health plan's listed formulary alternatives, the requested treatment with Trintellix represents the next best step in treatment of the patient's generalized anxiety disorder.
In this case, the prescribing clinician has documented that the patient has tried or failed formulary alternatives with a lack of clinical response/efficacy or adverse effect. The patient's proposed treatment with Trintellix is reasonable in view of the multiple failed trials with formulary alternatives including SSRIs (fluoxetine, sertraline and citalopram), duloxetine, bupropion and mirtazapine. The selection of a novel antidepressant, Trintellix, reflects sound medical judgment and is in the best interest of the patient in this case scenario. The patient's prescribing clinician has requested the Trintellix on the basis of the clinical history and current treatment recommendation for the use of Trintellix. The request for the Trintellix to treat generalized anxiety disorder is reasonable in this case scenario and is considered medically necessary, clinically appropriate and is in accordance with generally accepted standards of medical practice; This answer is consistent with the guidelines and scientific literature referenced below.