Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder (ADHD).
Treatment: Adderall extended release (XR) 10 milligrams (mg) OR (oral) CP24.

The insurer denied coverage for Adderall XR 10 mg OR CP24.  The denial is overturned.

This female has a diagnosis of ADHD and was prescribed Adderall XR 10 mg to target symptoms. She has been taking this medication for years with reported efficacy and lack of side effects or adverse reactions. She had adverse reaction and side effects to generic Adderall, so she required brand name Adderall XR. 
  
The medical records provided enough specific evidence to support that she required this medication. This patient has documentation of having a diagnosis of ADHD and Adderall XR is a Food and Drug Administration (FDA) approved medication to treat ADHD. According to the Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with ADHD it reports that short term efficacy of psychopharmacological interventions for ADHD were well established. It also reports that stimulants were considered highly efficacious in the treatment of ADHD with up to 75% clinical responders. Some patients respond to certain psychostimulants and not others. The psychostimulants include Methylphenidate products, amphetamine/dextroamphetamine products which include Adderall, Vyvanse (Lisdexamfetamine dimesylate), and Strattera (Atomoxetine) which is a norepinephrine reuptake inhibitor. The psychostimulants include Methylphenidate extended release (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. 

Dexmethylphenidate ER agents such as Focalin (brand name) are methylphenidates and useful to treat ADHD. Other psychostimulants include amphetamine/dextroamphetamine salts both regular and extended release and dextroamphetamine regular and extended release. Vyvanse is a different type of stimulant and is the 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. It is a different mechanism of action and an inactive prodrug which becomes active when ingested. Strattera, which is the brand name for Atomoxetine, is a nonstimulant blocking the Atomoxetine neurons and is also used to treat ADHD. Adderall is a psychostimulant in the amphetamine/dextroamphetamine class and is FDA approved for ADHD in people 6 years old and older. Adderall XR was FDA approved for ADHD in children and adolescents in 2001 and in 2004 Adderall XR was the first stimulant approved for ADHD in adults. Adderall is the brand name and amphetamine/dextroamphetamine is the generic equivalent. Both are FDA approved medications for ADHD in adults as well as children. The FDA maximum recommended dosage for Adderall XR for treating ADHD is 40 mg per day, so the request for 10 mg per day is considered within the FDA approved recommended dosing. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Adderall XR 10 mg OR CP24 is overturned. Medical Necessity is substantiated.