Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Adderall XR 10mg (pre-service)
The insurer denied the Adderall XR 10mg (pre-service)
The denial is overturned. 

The patient is a young adult male diagnosed with attention deficit hyperactivity disorder (ADHD). The patient has been effectively treated with stimulant medication, Adderall XR (extended release) (amphetamine-dextroamphetamine mixed salts) at a current dosage of 10 mg (milligrams) daily.

The patient has been treated with this medication at varying dosages for a couple of years and had previous treatment with Adderall XR (extended release).

The patient demonstrates a clinical response to the currently prescribed dose of Adderall/ amphetamine-dextroamphetamine mixed salts with therapeutic benefits and a satisfactory response, as well as tolerability. The patient has no co-morbid psychiatric disorders other than a remote diagnosis of intermittent explosive disorder. The patient does not have a co-occurring substance use disorder or significant general medical conditions other than obesity.

The health plan has denied coverage of the Adderall at the effective dosage of 10 mg (milligrams) daily indicating initially that the medical records were not submitted, and subsequently and erroneously reporting the diagnosis as "ACD" (attention concentration deficit) rather than ADHD; the miscommunication of the diagnosis as ACD (attention concentration deficit) triggered a denial of coverage.

Yes, the treatment with  Adderall XR 10 mg (milligrams) daily for ADHD (attention deficit hyperactivity disorder) 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 Adderall XR (extended release) (amphetamine-dextroamphetamine mixed salts extended release) at a current dose of 10 mg (milligrams) daily. Indeed, the 10 mg (milligrams) dose of Adderall XR (extended release) per day is medically necessary in this case in order to achieve a sustained therapeutic response with tolerability.

Thus, medical necessity is met as the requested benefit of Amphetamine-dextroamphetamine mixed salts extended release/Adderall XR (extended release). The Adderall XR (extended release) 10 mg (milligrams) daily is reasonable, 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 practice guidelines and the scientific literature, referenced below. The dosage is individualized and the Adderall XR (extended release) 10 mg (milligrams) daily is prescribed by a psychiatrist who has provided treatment to the patient for a couple of years. 

The requested Adderall XR (extended release)/ amphetamine-dextroamphetamine mixed salts extended release at a dosage of 10 mg (milligrams) daily has been effective and safe in the treatment of the patient's attention-deficit hyperactivity disorder. Again, stopping the Adderall XR (extended release) is more than likely to be detrimental to the patient with regard to a recrudescence of symptoms related to the ADHD (attention deficit hyperactivity disorder), and could reasonably result in a decline in the patient's occupational, social and/or daily functioning.
The patient's clinician, a behavioral health specialist, has requested approval for the Adderall XR (extended release) on the basis of the clinical history, diagnosis, submitted documentation and that the Adderall XR (extended release) at the current daily dose has been satisfactorily prescribed for this patient with a robust clinical response and improved functioning.

The requested benefit of Adderall XR (extended release) (amphetamine-dextroamphetamine mixed salts extended release) at the current dose of 10 mg (milligrams) daily for ADHD (attention deficit hyperactivity disorder) is clinically appropriate and medically necessary in this case scenario. Moreover, a denial of the benefit of amphetamine-dextroamphetamine mixed salts extended release (Adderall XR [extended release]) is more than likely to be detrimental to the patient, as he has been prescribed Adderall XR (extended release) for ADHD (attention deficit hyperactivity disorder) for the past several years with a satisfactory clinical response and improved functioning on this medication.