Diagnosis: Sleep apnea/Insomnia.
Treatment: Belsomra.
The insurer denied Belsomra.
The health plan's determination is upheld.

The patient is a male who is seeking approval for Belsomra. He was also noted to have untreated sleep apnea and a smoking history. An appeal letter noted that he has failed Doxepin, Ambien, and Lunesta. The denial was due to lack of documentation that the member was trialed on other medications (Ambien, Lunesta, Doxepin, and Elavil).

Belsomra is medically necessary for this patient. The patient has a history of sleep apnea. He has continued problems with sleep; mostly with early morning awakenings.
According to Kawabe et al, Prieto et al, and Qaseem et al, Belsomra is Food and Drug Administration (FDA) approved for insomnia treatment. This patient has failed multiple other medications such as Ambien, Lunesta, Doxepin, and Elavil. Belsomra is an appropriate treatment at this time.