Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Amphetamine/Dextroamphetamine (Adderall) 30 mg
The insurer denied coverage for Amphetamine/Dextroamphetamine (Adderall) 30 mg
The denial is overturned

This male reportedly was taking Amphetamine/Dextroamphetamine (Adderall) 30 mg (milligrams) per day for years with efficacy and had a diagnosis of ADHD. He also reportedly had a mood disorder and PTSD (post-traumatic stress disorder) diagnoses and had reports of mood swings, depression, flight of ideas, racing thoughts, tangential thought process, irritable mood, panic attacks, anxiety, attention and concentration problems. He reportedly also was taking Abilify, Gabapentin, Zoloft, and Oxycodone. 
 
The insurer denied coverage for Amphetamine/Dextroamphetamine (Adderall) 30 mg per day as not medically necessary treatment then. They stated that there was inadequate information to support the medical necessity of this medication then.
  
This reviewer disagrees with the decision to deny coverage for Amphetamine/Dextroamphetamine (Adderall) 30 mg per day as the medical records provided enough specific evidence to support that this medication was considered medically necessary treatment then. According to the Food and Drug Administration (FDA) it states that Adderall tablets contain d (dextro)-amphetamine and l (levo)-amphetamine salts in the ratio of 3:1. It also states that Amphetamines are non-catecholamine sympathomimetic amines with CNS (central nervous system) stimulant activity and are thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space. The maximum approved dose for dextroamphetamine/amphetamine is 40 mg per day for ADHD and 60 mg per day for narcolepsy as there was no reported specific literature supporting the efficacy and safety of doses higher than that. In this case this patient had a reported diagnosis of ADHD and had efficacy from years of taking Amphetamine/Dextroamphetamine (Adderall) 30 mg per day which is within the dosage guidelines of 40 mg per day maximum dosage for ADHD diagnosis. According to the NIH (national institute of health) and the National Library of Medicine (National Center for Biotechnology Information, "Dextroamphetamine-Amphetamine" by Shoar, Marwaha, and Molla it stated that the usual dosage range for treatment of ADHD with this medication was 5 to 40 mg per day in 1 to 3 divided dose and subsequent doses may be at 4 to 6 hours intervals with a maximum dosage of 40 mg per day. This patient was considered a candidate for Dextroamphetamine/Amphetamine (Adderall), and it was considered medically necessary to treat ADHD as he reportedly had efficacy for years without reports of side effects or adverse effects. He reportedly had other diagnoses of mood disorder and PTSD in addition to ADHD and reportedly was benefitting from this FDA approved medication. It would not have been in his best interest to stop an FDA approved medication that was effectively targeting ADHD symptoms and that also was within the FDA maximum daily dosage guidelines. As a result, the recommendation is to reverse the previous decision and approve coverage for Amphetamine/Dextroamphetamine (Adderall) 30 mg per day. It did not appear that the insurer acted in the best interest of the patient then. 

The insurer's denial of coverage for Amphetamine-Dextroamphet Tab 30 mg (Adderall) is overturned. Medical Necessity is substantiated.