Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention deficit hyperactivity disorder.

Treatment: Vyvanse 10 milligrams (mg) OR (oral) chew (chewable).

The insurer denied coverage for Vyvanse 10 milligrams (mg) OR chew.

The denial is upheld.

This child reportedly had difficulty paying attention, hyperactivity as it was reported that she was constantly moving and had difficulties with executive functioning. She reportedly had a diagnosis of attention deficit hyperactivity disorder (ADHD)-combined presentation. It was reported that she tried and failed Methylphenidate and Focalin XR (extended release) in the past. It was reported that she also took Fluoxetine and Escitalopram. It was reported that her psychiatrist recommended to start Vyvanse 10 mg per day to treat ADHD.
  
The insurer denied coverage for Vyvanse 10 mg per day. They stated that it was not considered medically necessary treatment. They stated that she had not taken or had a poor response to preferred medications including generic Adderall XR or Dexedrine Spansules. 
  
This patient reportedly tried both Methylphenidate and Focalin XR which is dexmethylphenidate. Other types of psychostimulants include extended release dextroamphetamine (Adderall-brand name) both XR and short acting, regular, and Dexedrine Spansules. Also, Strattera which is the brand name for Atomoxetine which is a nonstimulant blocking the presynaptic reuptake of norepinephrine neurons is another approved medication for ADHD. Vyvanse is a brand name medication and is called Lisdexamfetamine dimesylate (generic) and it is an inactive pro drug in which d-amphetamine is pharmacologically activated after oral ingestion. This has a different mechanism than the other mentioned psychostimulants as it is a pro drug needing to be activated after ingestion. 

This patient reportedly tried and failed some preferred formulary medications but only methylphenidate products including Methylphenidate and Focalin XR which is dexmethylphenidate. The formulary medications mentioned by the insurer, generic Adderall XR and Dexedrine Spansules, were not tried and although there is a reported nationwide shortage of Adderall, this patient did not try and fail or have adverse effects to the other formulary dextroamphetamine product, Dexedrine Spansules. Although Vyvanse is considered a Food and Drug Administration (FDA) approved medication for ADHD and this patient had a diagnosis of ADHD, there was no documentation that she had tried and failed or had adverse effects to Dexedrine Spansules which was on the formulary list. The psychiatrist reportedly prescribed this medication very recently. There were no reports in the provided medical records stating that she was taking this for a long period of time and having efficacy without adverse effects. The patient did not meet prior authorization criteria by the insurer as she did not try Dexedrine Spansules which was on formulary. The medical records did not support that she could only take Vyvanse and that this was the only medication medically necessary to treat this patient's ADHD symptoms. As a result, the recommendation is to uphold the previous decision and deny coverage for Vyvanse (Lisdexamfetamine) 10 mg capsules per day for the treatment of ADHD.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Vyvanse 10 milligrams (mg) OR (oral) chew is not substantiated.