Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD)
Treatment: Vyvanse (Lisdexamphetamine) chewable 20 mg
The insurer denied coverage for Vyvanse (Lisdexamphetamine) chewable 20 mg.
The denial is overturned.

This patient had a diagnosis of attention deficit hyperactivity disorder (ADHD) and according to the medical records was prescribed Vyvanse (lisdexamphetamine) chewable 20 mg (milligrams) by her pediatric neurologist. The patient reportedly had difficulty paying attention, listening, focusing, and her ADHD symptoms were causing clinically significant impairment in her academic functioning at school during the learning process, at home during homework time, and when trying to focus on a task at hand. She reportedly was failing mathematics. She was with an Individualized Education Program (IEP) in an integrated classroom. She reportedly had tried Focalin IR (instant release) and XR (extended release), Methylin Solution, Quillichew ER (extended release), and the Daytrana patch. The patient reportedly had an inability to swallow tablets or capsules and was very sensitive to texture.
    
This reviewer disagrees with the decision to deny coverage for Vyvanse (lisdexamphetamine) chewable 20 mg per day as the medical records provided enough specific evidence to support that she required this medication for treatment of her ADHD symptoms. According to the American Academy of Child and Adolescent Psychiatry March 2009 Volume 48 Issue 3, article, "Review of ADHD Pharmacotherapies: Advantages, Disadvantages, and Clinical Pearls by Daughton and Kratochvil pages 240-248, 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 OROS-osmotic release oral system. Methylphenidate uses an 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 an osmotic pump that gradually releases Methylphenidate producing an ascending serum concentration to approximate a 3 times daily dosing schedule. There also is short acting Methylphenidate (brand name Ritalin). The patient reportedly tried several other FDA (Food and Drug Administration) approved psychostimulants including Focalin IR and XR, Methylin Solution, Quillichew ER, and Daytrana patch. It was reported that the patient had an inability to swallow tablets or capsules and had sensitivity to texture. The FDA approved Adderall medication for oral use with the external capsule. Removing an external capsule of this medication could interfere with the bioavailability of the medication. Sprinkling capsules is not as exact and can lead to more uncertainty and she also could not reportedly tolerate tablets or capsules. She also tried Quillichew ER and it did not have reported efficacy so the chewable Vyvanse which is an FDA approved medication for treatment of ADHD was considered the next best option for this patient and the only other one that she could tolerate. As a result, the recommendation is to overturn the previous decision and approve Vyvanse chewable 20 mg per day for the treatment of her ADHD symptoms.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Vyvanse chewable (lisdexamphetamine) services is substantiated.