Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention-deficit/hyperactivity disorder (ADHD)

Treatment: QuilliChew extended release (ER) 20 milligram (mg) chewable tablets

The insurer denied coverage for QuilliChew ER 20 mg chewable tablets

The denial is overturned

This patient has severe attention-deficit/hyperactivity disorder (ADHD) symptoms including difficulty paying attention and listening, distractibility, difficulty with sustained attention, impulsivity, physical aggression, blurting out, interrupting, jumping on tables, climbing about, throwing objects, not following commands, turning lights on and off, running around without control, leaving his seat, difficulty waiting, defiance, and he had a diagnosis of ADHD-combined presentation. He also had a pediatric neurology consultation due to speech delays and also to rule out autism spectrum disorder in addition to ADHD. He tried Adderall extended release (XR) and had side effects including depression and more aggression and reportedly was unable to handle the texture of granules in capsules. 
  
The insurer denied the request for QuilliChew ER 20 mg per day for ADHD due to his young age.
  
The patient could not take capsules or tablets, and this is the only chewable Food and Drug Administration (FDA) approved medication for ADHD. Although the FDA recommended age is 6-12, this patient's ADHD symptoms were considered severe and interfered significantly with his ability to function and learn. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder reports that pharmacotherapy with psychostimulants are the treatment of choice for ADHD. Also, according to the AACAP March 2009 there are several different psychostimulants and Strattera (Atomoxetine) which are used to target ADHD symptoms including psychostimulants in the methylphenidate and amphetamine class. According to the FDA, the only FDA approved long-acting chewable psychostimulant is QuilliChew and QuilliChew ER comes in 20 mg, 30 mg, and 40 mg chewable tablets. It is not advisable to use Methylphenidate solution instead of a chewable pill because measuring this controlled substance with a solution is not as exact as the chewable pill. Also, crushing a long-acting psychostimulant interferes with the efficacy of the medication as it cannot be crushed but must be swallowed whole for the maximum effect. It was medically necessary for this child to receive the chewable QuilliChew ER 20 mg tablets per day as this is an FDA approved psychostimulant for ADHD, and even though he was younger than the FDA approved age, this chewable medication or a Daytrana patch were the only medications that he could take as he could not take oral pills. Both QuilliChew and Daytrana patch are FDA approved for ADHD but with his severe hyperactivity the chewable pills were preferred as the patch could fall off when his hyperactivity was so severe. This was a complex patient with developmental delays, aggressive and defiant behavior, severe hyperactivity, and attention who could not sit still or pay attention to learn and could not maintain behavioral control which put him and others at risk of harm. It is not uncommon for providers to use FDA approved medications for ADHD for children under 6 if their symptoms are severe and their functioning is significantly impaired or if they would be considered more of a danger to self or others without the medication. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for QuilliChew extended release (ER) 20 mg chewable tablets is overturned.