Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention deficit disorder.
Treatment: Vyvanse 40 milligrams (mg) capsule.
The insurer denied coverage for Vyvanse 40 mg capsule.
The denial is overturned.

This adult patient reportedly was taking Vyvanse 40 mg per day to target attention problems as the patient had a diagnosis of attention deficit disorder (ADHD)- inattentive presentation. The patient reportedly had been taking this with efficacy after reporting side effects when taking Adderall, the month prior. It was reported that the patient was recently seen by the provider. 
  
This reviewer disagrees with the decision to deny coverage for Vyvanse 40 mg per day to treat ADHD symptoms for this patient as the medical records provided support that this 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 ADHD reports that pharmacotherapy with psychostimulants are considered first line treatment. This patient had a diagnosis of ADHD - inattentive presentation and Vyvanse is considered a Food and Drug administration (FDA) approved medication for ADHD for adults as well as children and adolescents and has a unique mechanism of action. Vyvanse is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. This has a different mechanism than the other mentioned formulary psychostimulants. This medication gets activated after ingestion as it is a pro drug, so abuse potential is considered less than other psychostimulants. This patient reportedly tried and failed another psychostimulant as the patient reportedly took Adderall generic prior to starting Vyvanse. Adderall is a dextroamphetamine/amphetamine product and the patient reportedly had side effects. Taking another dextroamphetamine product was not considered in the best interest of the patient. Even though the patient reportedly did not try a formulary methylphenidate product, the patient reportedly had been taking Vyvanse with efficacy and lack of reported side effects. This FDA approved medication for treatment of ADHD in adults was considered a medically necessary treatment for this patient. It was not considered in the best interest to stop an FDA approved medication, with a unique mechanism of action to try another medication. Vyvanse was considered a medically necessary treatment. It was not as likely that another methylphenidate product or dextroamphetamine/amphetamine product would be more beneficial than continuing with Vyvanse, which was different than these medication classes, FDA approved for ADHD, and the patient reportedly was taking with reported efficacy and lack of side effects.  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 which has a unique mechanism of action. Vyvanse is considered an FDA approved medication for ADHD, this patient had a diagnosis of ADHD and the patient failed Adderall in the past so Vyvanse was considered medically necessary treatment. 

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 40 milligrams (mg) capsule is substantiated.