Adderall denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee is requesting Adderall for relief of her fatigue as well as improved focus and motivation. Findings: The physician reviewer found that Adderall has improved her fatigue and concentration symptoms in the past. Therefore, Adderall is medically necessary for the treatment of this patient.The enrollee was diagnosed with major depressive disorder (MDD), obstructive sleep apnea, and systemic lupus erythematosus. The enrollee reported having depression since her teens. The enrollee reported she was on Adderall with adequate relief of her fatigue as well as improved focus and motivation in the past. Recently, the enrollee endorsed poor memory and concentration, anhedonia, appetite changes, insomnia, decreased energy, excessive worry, and restlessness. Examination findings included that the patient had an anxious, irritable, and sad mood.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication Adderall. Findings: Approved pharmacological treatments for attention-deficit hyperactivity disorder (ADHD) include a range of stimulant medications such as methylphenidate and amphetamine, as well as non-stimulant agents with atomoxetine, guanfacine, and clonidine. Adderall is a stimulant medication that is considered a first-line treatment for patients with ADHD. In this case, the patient has a history of bipolar disorder type II and ADHD, inattentive type. The provider states that the patient has been treated with Ritalin, Effexor, Adderall, and Zyprexa. The patient reportedly experienced a psychotic reaction to Adderall many years ago, and he was reintroduced back onto treatment with Adderall at a gradual dose titration to 60 mg without side effects.

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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Adderall and (2) Ativan. The U.S. Food and Drug Administration (FDA) approves the use of Adderall for the treatment of attention deficit hyperactivity disorder (ADHD). The FDA notes that contraindications to Adderall include agitated states. In this case, while the patient reports problems with attention and concentration that they attribute to ADHD, these issues may be caused by a variety of mental health disorders, including major depressive disorder, bipolar disorder, generalized anxiety disorder, obsessive compulsive disorder, learning disorder(s), and various substance use disorders, or may be caused by general medical conditions, including hypothyroidism, hypoglycemia, anemia, sleep disorders, hearing and vision impairment, and seizure disorders.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Adderall, then check the rights and deadlines that apply to your plan.