Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder.
Treatment: Vyvanse 60mg Oral Caps.
The insurer denied: Vyvanse 60mg Oral Caps.
The denial is overturned.

The patient is an adult female diagnosed with attention deficit hyperactivity disorder (ADHD)-inattentive type. Comorbid psychiatric disorders include mild and recurrent major depressive disorder, generalized anxiety disorder with panic attacks and posttraumatic stress disorder (PTSD). There is no report of a co-occurring substance use disorder or a general medical condition that is a focus of treatment, or a diagnosis of narcolepsy or binge eating disorder. The patient has been prescribed Vyvanse 60 mg (milligrams) daily targeting symptoms of ADHD (attention deficit hyperactivity disorder), which include attention and concentration problems, difficulty in completion of tasks, difficulty listening and following directions, and other symptoms consistent with the diagnosis. After one month, Vyvanse was effective and well-tolerated with improved concentration, focus and functioning, as well as improved mood.
The health plan denied coverage of Vyvanse indicating that Vyvanse is non-formulary and that two formulary medications must be tried and fail before a coverage exception will be approved. The health plan suggests treatment with one of the formulary alternatives which include dextroamphetamine-amphetamine mixed salts (generic Adderall), or long-acting methylphenidate (generic Ritalin or Concerta). The denial and coverage determination were reviewed by the health plan's pharmacy benefit manager with application of the prior authorization criteria in keeping with the plan's prior authorization criteria and policy pertaining to a coverage exception. The request for Vyvanse was deemed to be not medically necessary.
The denial is being appealed, with the prescribing physician indicating that Vyvanse is medically necessary for this patient in view of the positive therapeutic response and tolerability. The appeal notes that the patient has failed treatment with Adderall, Ritalin, Concerta, Focalin, and guanfacine, as well as off label use of Wellbutrin. Treatment failures were either due to lack of effect or had resulted in adverse effects which included increased anxiety and worsening symptoms of the PTSD (post-traumatic stress disorder). The appeal also references Vyvanse's unique advantage with respect to abuse liability and noting that it only becomes active when digested in the stomach.

The requested Vyvanse is medically necessary for this patient.

The requested non-preferred Vyvanse is medically necessary in this case as opposed to the preferred formulary alternatives, such as amphetamine-dextroamphetamine extended release and methylphenidate extended-release (generic Adderall and Ritalin or Concerta). The patient has had adverse effects and/or lack of efficacy with the preferred formulary alternatives. Vyvanse at a daily dosage of 20 to 70 mg (milligrams) daily for the treatment of attention deficit hyperactivity disorder (ADHD) is reasonable (60 mg [milligrams] daily dose in this case), in the patient's best interest, and consistent with prevailing standards of medical practice, as well as the FDA (United States Food and 
Drug Administration)-indicated use for the treatment of ADHD (attention deficit hyperactivity disorder). Specifically, in this case, the patient has been effectively prescribed the requested treatment with Vyvanse daily in order to address symptoms of ADHD (attention deficit hyperactivity disorder) with improved functioning and mood. Thus, it is in the patient's best interest to receive this medication that the clinician had determined is clinically indicated and provides clear therapeutic benefit as opposed to the formulary alternatives.