Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder
Treatment: Vyvanse 60 milligram capsules
The insurer denied: Vyvanse 60 milligram capsules
The denial is overturned.

The patient is an adult male adult male diagnosed with attention deficit hyperactivity disorder (ADHD). There is no report of comorbid psychiatric disorder or co-occurring substance use disorder or a general medical condition that is a focus of treatment, nor is there a reported diagnosis of narcolepsy or binge eating disorder.
The patient has been prescribed Vyvanse with current dose of 60 mg (milligrams) taken daily with tolerability and a positive therapeutic response for the past 4 years. The current use of Vyvanse is known to improve functioning and has successfully addressed the symptoms of ADHD (attention deficit hyperactivity disorder) in clinical trials.
The health plan denied coverage for Vyvanse based on plan coverage guidelines and prior authorization criteria that requires treatment failure with alternatives (step therapy). The health plan's alternatives include amphetamine-dextroamphetamine, dexmethylphenidate, and methylphenidate extended-release formulations.
The prescribing physician and patient has appealed indicating that the patient is treated with Vyvanse at the current dosage with a positive therapeutic effect and tolerability. The appeal indicates that the current dose of Vyvanse at 60 mg (milligrams) has been prescribed for the treatment of the patient's ADHD (attention deficit hyperactivity disorder), and that Vyvanse has been prescribed for 4 years with relative stability and a positive therapeutic response. The appeal indicates that treatment with multiple alternative medications was not effective. The plan has covered the requested Vyvanse in the past according to the appeal.

The requested Vyvanse is medically necessary for this patient.

The requested Vyvanse is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-base treatment. The requested Vyvanse being provided in this case is clinically appropriate and is backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case. Moreover, treatment with a medication known to be effective and tolerated will be more likely to continue to work and be tolerated, as opposed to any of the health plan's alternatives. The dosage is individualized and has been prescribed with tolerability for four years. Moreover, the plan has covered the requested Vyvanse in the past, according to the appeal.
To switch this patient from a medication that is known to have been effective and well-tolerated in the past is not in the best interest of the patient. There is no evidence that the health plan's alternatives will be as effective for this patient, and the appeal indicates that multiple alternative formulations were not effective. Moreover, taking the patient off a medication that is known to have been effective and tolerated would place this patient at risk or would be detrimental to this patient with medical certainty. Therefore, the health plan should cover the requested treatment with Vyvanse.