Rx Management denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Concerta for treatment of the enrollee’s attention deficit hyperactivity disorder (ADHD). Findings: The physician reviewer found that stimulant medication is the gold standard pharmacologic intervention for ADHD. Concerta is a methylphenidate-based product approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD. Concerta is a central nervous system psychostimulant that has been shown to exert its clinical effect by blocking the reuptake of norepinephrine and dopamine in the prefrontal cortex. The unique extended-release tablet relies on osmotic pressure to steadily deliver methylphenidate resulting in a duration of effect that can approach 12 hours. The typical dose range of Concerta is between 18 mg and 72 mg once a day.

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensive outpatient program level of behavioral health treatment for treatment of her behavioral health conditions. Findings: The physician reviewer found that this case encompasses all elements of the bio-psycho-social-cultural model of conceptualization and generates impairment in multiple domains. The patient has attempted treatment of her illness burden in the outpatient setting. Her treatment has consisted of pharmacotherapy and psychotherapy, but has netted no meaningful treatment gains. Considering the illness burden and an undistracted therapeutic opportunity, intensive outpatient programming would be reasonably expected to significantly improve the patient’s condition. All told, intensive outpatient program level of behavioral health treatment is medically indicated for the treatment of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of diazepam, Adderall, and Ritalin titration therapy for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that Ritalin and Adderall are schedule II medications. These medications are highly controlled and regulated by the U.S. Drug Enforcement and Administration (DEA) and their use require frequent follow up. The records indicate that this patient had not followed up with his provider, which would be eight to nine months from the requested fill date. This length of follow up is not considered standard of care while prescribing schedule II medications. Therefore, it is appropriate and the standard of care for the provider to require face to face follow up prior to continuing schedule II medications.

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for Concerta and modafinil for treatment of the enrollee’s major depressive disorder. Findings: The physician reviewer found that Concerta is a methylphenidate-based product that was approved by the U.S. Food and Drug Administration (FDA) for the treatment of attention deficit hyperactivity disorder (ADHD) in 2000. Concerta is a central nervous system psychostimulant that is thought to exert its clinical effect by blocking the reuptake of norepinephrine and dopamine in the prefrontal cortex. The unique extended-release tablet relies on osmotic pressure to steadily deliver methylphenidate resulting in a duration of effect that can approach 12 hours. The typical dose range of Concerta is between 18 mg and 72 mg once a day.

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 Rx Managementwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.