Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder (ADHD)-inattentive type.
Treatment: Vyvanse 70mg (one capsule by mouth daily for one year).
The insurer denied the Vyvanse 70mg (one capsule by mouth daily for one year).
The denial is overturned.

The patient is an adult male. He is diagnosed with attention deficit hyperactivity disorder (ADHD)-inattentive type. No comorbid psychiatric disorders are reported and there is no report of a co-occurring substance use disorder or a general medical condition that is a focus of treatment, nor is there a diagnosis of narcolepsy or binge eating disorder. The patient has been prescribed Vyvanse 70 mg (milligrams) daily in view of a past history of a positive response for "several years" with improved symptoms and functioning. The patient's prescribing clinician is requesting coverage for treatment with Vyvanse for the treatment of ADHD (attention deficit hyperactivity disorder) in the context of a recent failed trial with the formulary alternative, generic Adderall.

The health plan denied coverage for resumption of use of Vyvanse as not medically necessary in keeping with plan exclusion and limitations of coverage. The health plan indicated that Vyvanse is non-formulary and that one additional formulary medication, generic Focalin, must be tried and fail before a coverage exception will be approved. The health suggests treatment with one of the formulary alternatives which include generic formulations of Adderall XR (extended release) and IR (immediate release), methylphenidate long acting or extended release, or Focalin with the latter medication recommended per the denial determination. The denial and coverage determination were reviewed by the health plan's pharmacy benefit manager with application of the prior authorization criteria in keeping with the plan guidelines and Policy pertaining to a coverage exception.

The prescribing physician has appealed indicating that the patient has been previously treated with Vyvanse with a positive effect and tolerability for several years.

Yes, the requested Vyvanse is medically necessary for this patient.
The service provided is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-base treatment. The requested services/treatment 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 formulary alternatives including the suggested alternative generic Focalin. Formulary alternatives have the probability of being effective and tolerated at no more than 70 percent versus 100 percent for Vyvanse with medical certainty.

This answer is in keeping with NY (New York) State instruction for this review, and is consistent with the published guidelines and scientific literature, referenced below.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested benefit with Vyvanse is provided for the purpose of treating ADHD (attention deficit hyperactivity disorder), and is clinically appropriate and indicated; and is entirely consistent with nationally recognized scientific evidence and prevailing medical standards and clinical guidelines, referenced below. 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 as noted in the appeal. There is no evidence that the remaining formulary alternatives will be as effective for this patient. 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.

This answer is in keeping with NY (New York) State instruction for this review.