Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder).
Treatment: Concerta (additional quantities) 54mg x2 tabs (108mg) per day.
The insurer denied: Concerta (additional quantities) 54mg x2 tabs (108mg) per day.
The denial is overturned.

The patient is a teenaged male diagnosed with attention deficit hyperactivity disorder (ADHD)-combined type. The patient has been prescribed brand Concerta, (methylphenidate HCL extended-release tablet), at a dosage of 108 mg (milligrams) daily with two 54 mg (milligrams) tablets per day for 6 years. The patient was diagnosed with neuropsychological testing which affirmed the diagnosis of ADHD (attention deficit hyperactivity disorder) with referral to the prescribing physician for treatment. The Concerta addresses core symptoms of ADHD (attention 
with improved functioning and tolerability. The patient failed treatment with generic Concerta, as well as trials with Focalin, Ritalin LA (extended release), and Vyvanse all of which caused adverse effects with intolerance and lack of therapeutic effect.
The health plan has denied coverage of the requested brand Concerta extended-release formulation, at the current dosage based on medical necessity and prior authorization guidelines. The denial determination indicates that plan criteria are not met with formulary provided including quantity limits and off-label maximum dosages. The prescribing physician is requesting coverage for continued treatment with Concerta (methylphenidate extended release) at the dose of 108 mg (milligrams) per day for ADHD (attention deficit hyperactivity disorder). The appeal indicates that the patient has been successfully treated with this medication at the effective dose of 108 mg (milligrams) per day with no adverse effects or side effects and a positive therapeutic response. Additionally, the appeal notes that a three-month trial of the generic formulation of Concerta resulted in adverse effects with intolerance, as did trials of three other stimulant medications outlined in the clinical summary. The appeal references the need to maintain uninterrupted treatment.

The requested health service is medically necessary.

The patient has been prescribed brand Concerta extended-release tablet, at a dosage of 108 mg (milligrams) daily with two 54 mg (milligrams) tablets per day for 6 years. The appeal reasonably argues that continued treatment with brand Concerta at the effective dose of 108 mg (milligrams) per day is clinically appropriate and medically necessary. The Concerta addresses core symptoms of ADHD (attention deficit hyperactivity disorder) with improved functioning and tolerability. The patient failed treatment with generic Concerta, as well as trials with Focalin, Ritalin LA (extended release), and Vyvanse, all of which caused adverse effects with intolerance and lack of therapeutic effect.
Moreover, the requested benefit with Concerta at a clinically appropriate dose of 108 mg (milligrams) daily is provided for the purpose of treating ADHD (attention deficit hyperactivity), as clinically appropriate. Additionally, the use of the Concerta, methylphenidate extended-release formulation has been prescribed for several years with a positive therapeutic effect and tolerability and improved functioning. The requested medication would be likely to be more effective than other formulary alternatives, and the appeal reasonably argues that it is clinically inappropriate to stop a medication that is effective and well tolerated in the context of several failed trials with other stimulants and the generic formulation of Concerta.

This answer is in keeping with published guidelines and scientific literature, referenced below, and in keeping with prevailing standards of medical practice for the treatment of the condition diagnosed in this case and is in keeping with the instructions for this binding New York State review.