Adderall Xr denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for brand name medication, Adderall XR.A review of the record indicates that the patient was previously treated with generic amphetamine-dextroamphetamine extended-release and was responding well. However, the patient's treatment course was interrupted due to the national shortage of this generic medication. The records further reflect that the patient has been without generic amphetamine-dextroamphetamine extended-release for the last two months. As a result, the patient reports a severe relapse in ADHD symptoms resulting in significant impairment. It is well established that patients with ADHD who are not optimally treated are at increased risk for co-morbid medical and psychiatric conditions.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall XR 15 mg daily. This patient’s records support a diagnosis of ADHD, predominantly inattentive type, which was diagnosed in childhood. The provider reported that the patient has been treated with Adderall XR, Concerta, and Focalin XR. Given the patient’s longstanding diagnosis of ADHD and reported benefit in her ADHD symptoms from the previous medication regimens, the patient is an ideal candidate for continued treatment for her ADHD. The patient’s provider has recommended treatment with Adderall XR 15 mg, which has been beneficial for the patient in the past.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name medication, Adderall XR Capsule Extended Release. The available records document that this patient has a diagnosis of major depressive disorder and generalized anxiety disorder. However, there is a lack of formal testing reported that supports a diagnosis of attention-deficit hyperactivity disorder (ADHD), to support an indication for Adderall XR. Specifically, the records provided for review fail to report symptoms that support a diagnosis of ADHD. Further, there is a lack of discussion of the patient’s assessment, plan, or prognosis for ADHD. Moreover, there is a lack of neuropsychological testing to support the ADHD diagnosis. The U.S.

The patient is a five-year-old male who has been diagnosed as having ADHD, hyperactive type. Pervasive developmental disorder - not otherwise specified, and mental retardation have been ruled out. The patient was initially treated with Adderall immediate release with positive response. The medication was later switched to Adderall XR (long-acting), which was given only once per day. The patient continues to have positive response to Adderall therapy. The patient has not been tried on any other psychostimulant. A request has been made for authorization of Adderall XR. The Health Plan has denied the request on the basis that Adderall XR is not medically necessary. Though the submitted records indicate the patient has had a positive response to Adderall XR it has not been established that Adderall XR is medically necessary for treatment of the patient’s ADHD.

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 Xr, then check the rights and deadlines that apply to your plan.