ADD ADHD Rx denials: what the review data shows

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Focalin (dexmethylphenidate) extended-release capsule (One capsule 3 times daily for 93 capsules monthly) purchased and going forward. According to medical literature, an individual patient’s genetic makeup and metabolism can lead to significant variability in a potential drug’s interaction with a specific patient. Oftentimes, a long-acting stimulant does not remain effective as long as expected.

Findings: The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for the brand name medication, Concerta. Stimulant medications, including methylphenidate formulations, are first-line pharmacological treatment for patients with attention-deficit hyperactivity disorder (ADHD). Approximately 70% of patients with ADHD demonstrate immediate improvement in attentiveness and reduced distractibility with stimulant therapy, with moderate-to-large effect sizes. Extended-release (ER) formulations such as Concerta provide six to 10 hours of symptom control with once-daily dosing, which improves medication adherence compared to immediate-release formulations. In this case, the patient has tried and failed multiple generic Concerta alternatives in the past, as well as multiple other stimulants and stimulant formations.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vyvanse 40 mg. Cannabis use disorder has been associated with several psychiatric disorders, in particular, attention deficit hyperactivity disorder (ADHD). In this case, while cannabis use disorder is not listed in the patient’s problem list, the records report a history of cannabis use disorder, and elements of the patient’s recent history suggest he meets the criteria for the disorder, including his continued desire and intent to use cannabis despite adverse outcomes. The intersection and often overlapping effects of cannabis and ADHD can be challenging for the clinician. Tetrahydrocannabinol (THC) binds to cannabinoid receptors in the brain and alters systems involved in memory, concentration, and time perception.

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 patient’s medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for ADD ADHD Rxwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.