Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder. 
Treatment: Vyvanse 10 mg cap. 

The insurer denied coverage for Vyvanse 10 mg cap. 

The denial is overturned. 

This adult patient has a diagnosis of attention deficit hyperactivity disorder (ADHD) and had attention problems interfering with occupational functioning and interpersonal functioning. It was reported that the patient was having difficulty completing assignments and feared that one would get fired. It also was reported that the symptoms were detrimental to the patient's relationship. The patient had anxious mood, nervousness, and was constantly biting fingernails. The patient was taking Adderall extended release (XR) and had taken Adderall immediate-release (IR) and had side effects of worsened anxiety and irritability. The patient had also tried Methylphenidate and also had side effects. The patient was prescribed Fluoxetine for anxiety. The request by the provider was for Vyvanse 10 milligrams (mg) per day to target ADHD symptoms. 
  
The medical records support that Vyvanse 10mg Cap was considered a medically necessary treatment. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder reports that pharmacotherapy with psychostimulants are considered first line treatment for ADHD. This patient has a diagnosis of ADHD and Vyvanse is considered a Food and Drug Administration (FDA) approved medication for ADHD and has a unique mechanism of action. Vyvanse (Lisdexamfetamine dimesylate) is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. This has a different mechanism than the other mentioned psychostimulants as it is a prodrug needing to be activated after ingestion. This medication gets activated after ingestion as it is a prodrug meaning that abuse potential is considered less than other psychostimulants. This patient tried and had reported side effects of worsened anxiety and irritability when taking the two main types of psychostimulants including generic Adderall IR and generic Adderall XR and 1 methylphenidate product, Ritalin (Methylphenidate). Taking another methylphenidate product such as generic Metadate or another dextroamphetamine product such as Dexedrine is not considered in the patient's best interest. The psychostimulants showed some efficacy, but the patient had intolerability; taking another psychostimulant such as Vyvanse with its unique mechanism of action and is FDA approved for ADHD, is considered medically necessary treatment for this patient. It was not as likely that another methylphenidate product or dextroamphetamine/amphetamine product would be more beneficial than trying Vyvanse which was different than these medication classes. It was considered less likely that other methylphenidate and amphetamine/dextroamphetamine medications still on formulary and the preferred list would be more effective than Vyvanse. 

Vyvanse is considered an FDA approved medication for ADHD and this patient has a diagnosis of ADHD. The patient reported side effects to 3 medications including 1 methylphenidate and 2 dextroamphetamine/amphetamine products, making Vyvanse a medically necessary treatment for the ADHD. Prior authorization was not considered necessary. As a result, the recommendation is to overturn the previous decision and approve coverage for Vyvanse (Lisdexamfetamine) for the treatment of ADHD. It did not appear that the health care plan acted in the best interest of the patient. 

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 10 mg cap is substantiated.