Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention-deficit/hyperactivity disorder. 
Treatment: Quillivant XR (extended release) 25mg (milligrams)/ 5ml (milliliter) OR (oral) SRER (sustained release/extended release) Suspension. 
The insurer denied: Quillivant XR 25mg / 5ml OR SRER Suspension. 
The denial is overturned. 

The patient is a school age male child with medical history significant for attention-deficit/hyperactivity disorder (ADHD) combined type and dyslexia. He has difficulty completing his work in the allotted time. He has marked deficits in reading decoding and fluency eroding comprehension. He demonstrates marked problems in interference control, processing speed, and working memory. He has a history of inability to swallow pills as well as negative side effects with stimulant medications at standard dosing. The plan for Quillivant liquid was to start at low dosing and taper up to a therapeutic dose. 

The requested Quillivant medication is medically necessary and appropriate for this child. 

Attention-deficit disorder is thought to be the most common psychiatric disorder of school-age children, with an incidence of 3-7%. Although the cause is unknown, there are many theories under investigation involving brain anatomy and chemistry. Genetics and environmental factors may also play important roles. A person with attention-deficit/hyperactivity disorder may experience difficulties in many aspects of life, including the processing of sensory information and may also suffer from comorbid disorders such as autism, Tourette's, or other mental illnesses. Stimulants are the most common medications used to treat children with attention-deficit/hyperactivity disorder. The mechanism of action involves release of dopamine and norepinephrine into the nervous system. "Amphetamine actions include dopamine and norepinephrine transporter inhibition, vesicular monamine transporter-2 (VMAT-2) inhibition, and monoamine oxidase activity inhibition. Methylphenidate actions include dopamine and norepinephrine transporter inhibition, agonist activity at the serotonin type 1A receptor, and redistribution of the VMAT-2 [vesicular monamine transporter-2]. There is also evidence for interactions with glutamate and opioid systems. (1)" Both classes of stimulants have been shown to 
be of comparable efficacy. While the tolerability and safety profiles are generally comparable, amphetamines are more likely to cause weight loss and insomnia than methylphenidate preparations. And even though both medication classes increase synaptic availability of dopamine and norepinephrine, there are differences in the specific cellular mechanisms of action that may influence an individual's response to treatment. It is noted that this patient cannot tolerate pills. There are formulations that do not require swallowing pills. However, he also has history of side effects, and his doctor plans to trial very low dose medication to establish tolerability and then increase slowly up to the therapeutic range. This is only something that can be accomplished with a liquid preparation. Quillivant is the only liquid formulation. Opening capsules onto food does not offer the necessary precision that this child requires. The requested Quillivant is medically necessary and appropriate.