Attention Deficit Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

The patient is a 21-year-old female with a long and extensive history of psychiatric disorders including depression, anxiety, attention deficit disorder, obsessive-compulsive disorder and substance abuse. Her alcohol abuse began approximately nine months prior to admission. She had participated in outpatient psychotherapy with medication management, but had not been hospitalized in the past. She was admitted for subacute psychiatric treatment in September 2005 and discharged in October 2005 with a plan for residential treatment.

The parent of a 12-year-old male enrollee has requested Daytrana transdermal patch for the treatment of the enrollee’s attention deficit disorder (ADD). Findings: The physician reviewer found that the relevant evidence demonstrates that Daytrana transdermal patches are medically necessary for this patient. Adler and colleagues support this finding based on their randomized, double-blind, placebo-controlled, 6-month trial examining the efficacy of the atomoxetine in ameliorating symptoms through the evening hours. Adler and colleagues concluded that in their study of 94 patients randomized to atomoxetine and 112 patients randomized to placebo, the once-daily morning-dosed atomoxetine was efficacious for treating ADHD in adults when measured 10 weeks and 6 months after initiating treatment.

Where the denial was upheld

Physician 1: The patient is a 12-year-old male with diagnoses of attention deficit disorder (ADD), Asperger’s syndrome and oppositional/defiant disorder. He was treated with biofeedback therapy from January 2004 through July 2004. The record also indicates the patient was prescribed Adderall in 2003. The parent’s request for reimbursement for the therapy provided from March 2004 through May 2004 was denied by the Health Plan citing the experimental/investigation nature of neuro/biofeedback therapy for the treatment of ADD.The use of neuro/biofeedback to treat ADD and other related conditions is not considered standard practice by either the American Academy of Child and Adolescent Psychiatry or the American Academy of Pediatrics. The latter organization lists EEG biofeedback among the “unproven treatments” for attention deficit disorders.

The patient is a 13-year-old male who was diagnosed with attention deficit disorder (ADD) approximately six years ago. He also has a history of vocal and motor tics as well as obsessive behavior. A SPECT scan performed on 3/18/04 demonstrated brain trauma with decreased left and right anterior pole and decreased posterior medial cerebellar profusion as well as parietal lobe dysfunction. The patient’s parent has requested reimbursement for the SPECT scan. The Health Plan has denied coverage stating the SPECT scan at issue is considered experimental.SPECT brain scans are not routine in the evaluation of attention deficit disorder. Even with the history of problems at birth and fetal distress, a SPECT scan is not used except on a research basis. The standard of care for ADD does not include SPECT scanning.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for attention deficit disorder was denied, the published record says the denial is worth fighting.