Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention deficit hyperactivity disorder, combined type (F90.2). 
Treatment: Intuniv Tab ER 24h. 

The insurer denied the Intuniv Tab ER (extended release) 24h. 
The denial is upheld. 

The patient is a male who was reported to have been diagnosed with attention deficit hyperactivity disorder, combined type (F90.2). The patient's provider is requesting the use of the nonformulary medication, brand name Intuniv ER (extended release) 24HR (hours) (guanfacine) 3 mg (milligram) tablet for treatment of the patient's symptoms. The requested medication was noted to have been previously denied coverage by the health plan, as there was no indication that the patient had failed generic formulations of the requested medication or had adverse effects or contraindications to the use of other formulary medications available for treatment of the patient's symptoms. 

An appeal letter provided by the treating provider indicates that the patient had previously failed a trial of generic extended release guanfacine at the highest dosage. The patient was reported to have been unable to tolerate the medication. He was reported to have poor sleep compared to the brand name medication. However, no clinical documentation was provided to indicate the same. There was no indication including clinical documentation or pain complaints report that indicate that the patient had been previously prescribed generic extended release guanfacine. 

Most recently, the patient was noted to have been seen for a clinical encounter. The patient was reported to have difficulties falling asleep with generic formulation of guanfacine. Medications prescribed include Vyvanse (lisdexamfetamine). The patient was noted to have been seen for a clinical encounter. He was noted to have been treated with psychotropic medications including Vyvanse (lisdexamfetamine) and Intuniv (guanfacine), in addition to Ritalin (methylphenidate). Previous clinical encounters indicate no significant change in the patient's medication regimen. Dosages were noted to have been optimized for symptom control. 

No, based on current peer-reviewed, evidence-based medical literature, the requested nonformulary medication (brand name Intuniv ER [extended release] 24 hour 3 milligram tablet) was not found to be exclusively medically necessary for treatment of the patient's symptoms related to attention deficit hyperactivity disorder. 
The patient is a male who was reported to have been diagnosed with attention deficit hyperactivity disorder, combined type (F90.2). The patient's provider is requesting the use of the nonformulary medication, brand name Intuniv ER (extended release) 24 hour (guanfacine) 3 mg (milligram) tablet for treatment of the patient's symptoms. Clinical documentation provided indicates that the patient was prescribed Vyvanse (lisdexamfetamine) and Intuniv (guanfacine) for several years for treatment of attention deficit activity disorder. There is no indication that the patient was treated with any other medication, including other formulary medications for symptoms related to attention deficit hyperactivity disorder. 

There is no evidence in the current peer-reviewed, evidence-based medical literature to indicate that the requested nonformulary medication would be more effective or would have less adverse effects than other formulary medications that are available for treatment of attention deficit hyperactivity disorder, including generic formulations of guanfacine (1-8). 

There are several formulations of alpha agonists that are available for treatment of attention deficit hyperactivity disorder. Evidence in current medical literature does not indicate that brand name Intuniv ER (extended release) 24 hour would be superior to other formulations. Therefore, based on current peer-reviewed, evidence-based medical literature, the requested nonformulary medication was not found to be exclusively medically necessary for treatment of the patient's symptoms related to attention deficit hyperactivity disorder. 

Yes, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.