Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD). 
Treatment: Vyvanse. 

The insurer denied coverage for Vyvanse. 

The denial is upheld. 

This child had Attention Deficit Hyperactivity Disorder (ADHD) symptoms including attention problems, distractibility, impulsivity, and hyperactivity. It was reported that the provider requested coverage for Vyvanse 10 mg (milligrams) per day to target ADHD symptoms as the patient reportedly had a diagnosis of Attention Deficit Hyperactivity Disorder-combined presentation. 
  
The reviewer agrees with the decision to deny coverage for Vyvanse 10 mg per day as the medical records that were provided for review stated that the patient tried all formulary medication with either lack of efficacy or adverse effects, but the medical records did not specifically state which medications were tried and what dosages and durations at which they were tried. 

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. Also, the American Academy of Pediatrics reports that psychostimulants are considered standard treatment for ADHD. 

According to Daughton and Kratochvil, there are several different psychostimulants and Strattera which are used to target ADHD symptoms. Psychostimulants include Methyphenidate ER [extended release] (brand name is Concerta) which is a pump OROS [osmotic release oral system] Methyphenidate using osmotic delivery system in which the tablet is coated with 22% immediate release Methylphenidate for the initial dosing and the long duration component is delivered by osmotic pump that gradually releases Methylphenidate producing an ascending serum concentration to approximate a 3 times daily dosing schedule. There also is short acting Methylphenidate (brand name Ritalin). Also, other methylphenidate products include dexmethylphenidate ER agents such as Focalin (brand name). Other types of psychostimulants include extended release dextroamphetamine (Adderall-brand name) both XR [extended release] and short acting regular. Also, Strattera which is the brand name for Atomoxetine which is a nonstimulant blocking the presynaptic reuptake of norepinephrine neurons is another Food and Drug Administration (FDA) approved medication for ADHD. Vyvanse is a brand name medication and is called Lisdexamfetamine dimesylate (generic) and it is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. There was no specific documentation in the medical records showing that this patient tried all of the other FDA approved formulary medications for ADHD and Vyvanse was not on formulary for this insurance so there was not adequate specific evidence to support that the patient did try all the formulary medications for ADHD including Dextroamphetamine and Atomoxetine. 

Vyvanse 10 mg capsules per day for ADHD treatment for this patient is not medically necessary.  It appeared that the insurer acted reasonably and with sound medical judgment. 

Based on the above, the medical necessity for the Vyvanse is not substantiated. The insurer's denial is upheld.