Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD)
 
Treatment: Jornay PM 40 mg OR CP24

The insurer denied the Jornay PM 40 mg OR CP24. The denial was upheld. 

This patient is a male child who has been followed by his pediatrician for complaints of  
attention problems and hyperactivity consistent with Attention Deficit Hyperactivity Disorder (ADHD). It was reported that he begins his morning with difficulties due to his symptoms and again after school through his bedtime. He had been treated with Methylphenidate ER, Methylin, Metadate, and Tenex. Jorney PM 40 mg to target ADHD symptoms was recommended. 

This reviewer agrees with the decision to deny coverage for Jorney PM 40 mg for ADHD as this patient did not try all of the formulary Food and Drug Administration (FDA) approved medications for ADHD.  According to the Journal of the American Academy of Child and Adolescent Psychiatry - March 2009, there are several psychostimulant medications used to treat ADHD symptoms with equal efficacy.  There are Methylphenidate products and amphetamine products.  Concerta is Methylphenidate ER (brand name is Concerta) which is a pump OROS-osmotic release oral system Methylphenidate 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 are the amphetamine medications including extended release dextroamphetamine (Adderall XR) and regular dextroamphetamine (Adderall).  Jorney PM is an FDA approved stimulant in the methylphenidate family for ADHD.  Jorney comes in 20, 40, 60, and 100 mgs.  It is given in the evening and has a delay in effect for 12 hours after ingestion.  It has a delayed and extended release and has an outer layer that delays 10-12 hours so that the full therapeutic blood level of methylphenidate occurs 12 hours later and targets the morning and throughout the day.  It is FDA approved for 6 years and older.  Although it is FDA approved for ADHD, this patient did not try all formulary medications and there were no contraindications to all formulary medication to treat ADHD.  This patient tried methylphenidate products including methylphenidate ER, Methylin, and Metadate.  He also tried Tenex which is an FDA approved medication for ADHD and is an alpha 2 adrenergic agonist.  However, this patient did not try other FDA approved medications on formulary for ADHD including dextroamphetamine products such as Adderall and Adderall XR which are amphetamine/dextroamphetamine products, Zenzedi which is dextroamphetamine, or Dexedrine Spansules.  These reportedly all are FDA approved medications for ADHD which were on formulary.  Also, there were no contraindications for not trying these formulary FDA approved medications for ADHD.  suggests equal efficacy in the treatment of ADHD.  There were no reports of cardiac or other medical conditions, substance use problems, or other reasons for contraindication to the formulary FDA approved medications.  There also were no reports that he tried and failed these other FDA approved formulary medications or had adverse effects from them. 

The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

The carrier's denial of coverage for the medication Jornay PM 40 mg OR CP24 for the treatment of attention deficit hyperactivity disorder is upheld.  The medical necessity is not substantiated.