Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder

Treatment: Qelbree 200 milligram (mg) capsule extended release (ER) 24 hours (H)

The insurer denied coverage for Qelbree 200 milligram (mg) capsule extended release (ER) 24 hours (H)

The denial is overturned

This adolescent reportedly had attention problems, distractibility, difficulty listening, difficulty following through with instructions, was losing things, forgetful, fidgeting, leaving his seat, interrupting others, and was intrusive. The patient reportedly had a diagnosis of attention deficit hyperactivity disorder (ADHD). The patient reportedly tried other psychostimulants including Adderall extended-release (XR), Dexmethylphenidate XR, and Vyvanse with lack of reported efficacy. It was reported that the patient's provider prescribed Qelbree 200 milligrams (mg) to target ADHD.
  
The insurer denied coverage for Qelbree 200 mg extended-release (ER) (Viloxazine) stating that it was not considered medically necessary treatment then. They stated that in order to meet their prior authorization criteria one needs to have a diagnosis of ADHD, be at least 6 years old, and had drug failure or serious side effects to Atomoxetine and one long-acting medication such as dexmethylphenidate ER, amphetamine/dextroamphetamine ER, or guanfacine ER.
  
The reviewer disagrees with the decision to deny coverage for Qelbree 200 mg ER (Viloxazine) as the medical records provided enough specific evidence to support that Qelbree was considered medically necessary treatment for this patient then. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children and Adolescents with ADHD reports that short term efficacy of psychopharmacological interventions for ADHD were well established. It also reports that stimulants were considered highly efficacious in the treatment of ADHD with up to 75% clinical responders. It states that physicians can chose from 2 stimulant types-methylphenidate or amphetamines because evidence suggests equal efficacy in the treatment of ADHD. 

The insurer's criteria to try Atomoxetine and a long acting psychostimulant appeared reasonable and this patient tried 3 long acting psychostimulants, but because the patient was already taking Qelbree which was Food and Drug Administration (FDA) approved to treat patient's ages 6-17 and the patient was within this age range with a diagnosis of ADHD, and had reported efficacy, it was considered medically necessary treatment for this patient then so prior authorization through the insurer's criteria was not considered necessary then. If the patient had not been taking Qelbree, then it would have been reasonable to try Atomoxetine, which is a nonstimulant medication similar to Qelbree to treat ADHD. However, the patient reportedly had established efficacy with this FDA approved medication, so it was considered medically necessary treatment then. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Qelbree 200 milligram (mg) capsule extended release (ER) 24 hours (H) is substantiated.