Appeal type: Medical necessity
Decision: Overturned

Diagnosis: attention deficit hyperactivity disorder (ADHD), inattentive type
Treatment:  Amphetamine- Dextroamphet  ER(extended release) 25mg (milligrams) OR CP24 (oral capsule once a day).
The insurer denied the Amphetamine- Dextroamphet  ER(extended release) 25mg (milligrams) OR CP24 (oral capsule once a day).
The denial is overturned.

The patient is an adolescent female. She is diagnosed with attention deficit hyperactivity disorder (ADHD), inattentive type. The patient has been effectively treated for approximately 10 years with stimulant medication, amphetamine-dextroamphetamine mixed salts (Adderall XR) with the extended-release formulation at a dose of up to 25 mg (milligrams). The Adderall XR (extended release) at the current dosage of 25 mg (milligrams) has been effective with regard to symptoms relief and ability to function with daily activities; the dose was titrated to 25 mg (milligrams) daily approximately three years ago with a satisfactory clinical response and tolerability. After a brief hiatus, the patient decided to restart the amphetamine-dextroamphetamine mixed salts extended-release medication to achieve the same clinical benefit. No other medications have been prescribed for ADHD (attention deficit hyperactivity disorder), and there are reported comorbidities that include sensory processing difficulty and an articulation disorder. The patient does not have a co-occurring substance use disorder, and there is no report of misuse of the prescribed amphetamine-dextroamphetamine mixed salts. The current dosage is consistent with recommended dosage range for this medication, and the dosage has been individualized to clinical response.

The health plan has denied coverage of the amphetamine-dextroamphetamine mixed salts extended-release medication on the basis of the health plan's criteria and guidelines that require a diagnosis of ADHD (attention deficit hyperactivity disorder) and use of the medication at the FDA (United States Food and Drug Administration)-recommended dosage range, as well as participation in the state prescription drug monitoring program (PDMP). The health plan denial indicated that there were no medical records submitted to substantiate the diagnosis or use of the requested amphetamine-dextroamphetamine mixed salts extended-release medication.

The patient's prescribing clinician, a psychiatrist, has requested coverage for the amphetamine-dextroamphetamine mixed salts extended-release medication at the effective dose of 25 mg (milligrams) daily or 30 caps per 30 days on the basis of the clinical history, diagnosis, submitted documentation, and that the Adderall XR (amphetamine-dextroamphetamine mixed salts) with the current dosing schedule has been safely prescribed for this patient with a clinical response and improved functioning. The prescribing physician indicated that the restart of the amphetamine-dextroamphetamine mixed salts extended-release medication is medically necessary as the medication has worked with a positive effect and tolerability. The appeal asserts that to deny coverage of the amphetamine-dextroamphetamine mixed salts extended-release medication or to stop the amphetamine-dextroamphetamine mixed salts extended-release medication would be detrimental or harmful to the patient.

Yes, the requested health service is medically necessary for this patient.
The patient is diagnosed with ADHD (attention deficit hyperactivity disorder) and has demonstrated an optimal response to dosing of the amphetamine-dextroamphetamine mixed salts extended-release at a daily dose of 25 mg (milligrams) in order to achieve a sustained therapeutic response with tolerability. Moreover, the current dosage is within recommended dosage range for this medication, and the dose is individualized as clinically appropriate.

Thus, medical necessity is met, as the requested amphetamine-dextroamphetamine mixed salts extended-release at a daily dose of 25 mg (milligrams) is clinically appropriate, and is in keeping with prevailing standards of medical practice, as well as the published guidelines and the scientific literature, referenced below.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient is diagnosed with ADHD (attention deficit hyperactivity disorder) and has demonstrated a satisfactory clinical response to dosing of the amphetamine-dextroamphetamine mixed salts extended-release formulation at a daily dose of 25 mg (milligrams), as noted in the clinical summary. Indeed, the continued use of amphetamine-dextroamphetamine mixed salts is reasonable in this case in order to sustain a therapeutic response with tolerability. The current effective dosage, amphetamine-dextroamphetamine mixed salts extended-release formulation is clinically appropriate, and in the best interest of the patient, and is in keeping with prevailing standards of professional practice, as well as the published guidelines and the scientific literature, referenced below.