Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder

Treatment: QuilliChew ER (methylphenidate hydrochloride) 20 milligrams (mg) (ER CHW)

The insurer denied coverage for QuilliChew ER 20mg ER CHW

The denial is overturned

The patient is a female reportedly had a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and had difficulty with attention. She reportedly also had learning disorder. She reportedly had anxiety symptoms. She had poor sleep. She reportedly had tried Adderall extended-release (XR) and Adderall immediate-release (IR) and Concerta which is long acting Methylphenidate. She also took Mirtazepine and Melatonin. It was reported that her pediatric nurse practitioner recommended QuilliChew ER 20 mg per day as the patient was refusing liquid methylphenidate and there were concerns that this also was not actually methylphenidate. It was reported that the patient also flushed Methylphenidate in the toilet.
    
According to the American Academy of Child and Adolescent Psychiatry March 2009 there are several different psychostimulants and Strattera (Atomoxetine) which are used to target ADHD symptoms. Psychostimulants include Methylphenidate ER (brand name is Concerta) which is a pump osmotic release oral system (OROS) Methylphenidate using osmotic delivery system in which the tablet is coated with 22 % immediate release Methylphenidate for the initial dosing and the long duration component is delivered by osmotic pump that gradually releases Methylphenidate producing an ascending serum concentration to approximate a 3 times daily dosing schedule. There is short acting Methylphenidate (brand name Ritalin). Other methylphenidate products include dexmethylphenidate ER agents such as Focalin (brand name). Other types of psychostimulants include extended release dextroamphetamine (Adderall-brand name) both XR and short acting regular. Strattera which is the brand name for Atomoxetine which is a non-stimulant blocking the presynaptic reuptake of norepinephrine neurons is another Food and Drug Administration (FDA) approved medication for ADHD. Vyvanse is a brand name medication and is called Lisdexamfetamine dimesylate (generic) and it is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. According to the FDA, the only FDA approved long acting chewable psychostimulant is QuilliChew and QuilliChew ER comes in 20 mg, 30 mg, and 40 mg chewable tablets. The request was for 20 mg of QuilliChew ER per day as this is long acting and it is chewable. It was reported that the patient took FAdderall XR and Adderall IR and Concerta which is long acting Methylphenidate and needed more long term coverage and needed chewable as she was refusing other oral forms of medication. Also, it is not advisable to use Methylphenidate solution instead of a chewable pill because measuring this controlled substance with a solution is not as exact as the chewable pill. Also, the FDA did not approve Focalin or Ritalin LA (long acting) to be opened up from the capsule and sprinkled on food as that could interfere with the bioavailability of the medication and its efficacy. The FDA approved theses medication for oral use with the external capsule. Removing an external capsule of these medications could interfere with the bioavailability of the medications. Also, crushing a long acting psychostimulant may interfere with the efficacy of the medication as it cannot be crushed but must be swallowed whole for the maximum effect. Also sprinkling capsules is not as exact and can lead to more uncertainty. It appeared medically necessary for this child to receive the chewable QuilliChew ER 20 mg tablets per day to target ADHD symptoms as this is an FDA approved psychostimulant for ADHD and is considered long acting, and she had a diagnosis of ADHD. She also was not tolerating oral psychostimulants.

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for QuilliChew ER 20mg ER CHW is reversed. Medical necessity is substantiated.