Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has authorization and coverage for a medication regimen of Adderall (combination of Adderall XR 30 mg and Adderall IR 10-20 mg).At issue in this case is whether the requested medication regimen of Adderall (combination of Adderall XR 30 mg and Adderall IR 10-20 mg) is medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Adult ADHD is debilitating, but concurrent stimulant use at the same time as substances such as cannabis have been controversial, as they have competing effects. Urine drug screening, substance use treatment or dual diagnosis treatment would be indicated to assist patients in recovery from substances while continuing treatment for ADHD. Moreover, Post and Kulansik indicate, To monitor for misuse or diversion of stimulants, family physicians should consider using a controlled substances agreement and random urine drug screening in addition to regular follow-up visits.In this case, the patient was diagnosed with ADHD previously and has benefited from treatment with Adderall. The patient is seeking to continue treatment for ADHD with Adderall. Per the records, he has refused urine drug screening due to his religious beliefs. In this setting, the medical evidence supports accompanying urine drug screening or substance use treatment in order to monitor for misuse or diversion of stimulants. Moreover, the patient has a history of past substance use. Therefore, Adderall is not indicated in this case. In this patients case, the requested medication regimen of Adderall (combination of Adderall XR 30 mg and Adderall IR 10-20mg) is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication regimen of Adderall (combination of Adderall XR 30 mg and Adderall IR 10-20mg) is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the requested medication regimen of Adderall (combination of Adderall XR 30 mg and Adderall IR 10-20mg) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the requested medication is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.