Vyvanse denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Vyvanse. The records document that this patient has symptoms of impaired processing speed, working memory, and learning. The records document that the patient has difficulty following instructions. Although the diagnosis of attention deficit hyperactivity disorder (ADHD) is not listed in the records, the patient demonstrated improvement in his school performance while treated with Vyvanse, and his symptoms are suggestive of ADHD, which frequently coexists with autism spectrum disorder. Previous treatment with Adderall XR and Concerta were ineffective, and Focalin caused insomnia. In the medical literature, Najib and colleagues describe that Vyvanse is a stimulant agent with low abuse and diversion potential that can be beneficial in the treatment of ADHD in children and adults.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vyvanse 30 mg for treatment of the enrollee’s attention deficit hyperactivity disorder (ADHD). Findings: The physician reviewer found that Vyvanse is a central nervous system stimulant approved by the U.S. Food and Drug Administration for the treatment of ADHD. The compound is a prodrug of dextroamphetamine. After oral administration, lisdexamfetamine is rapidly absorbed and converted to dextroamphetamine, which is responsible for the drug’s psychoactive properties. Amphetamines generate a clinical effect by inhibiting norepinephrine and dopamine reuptake into the presynaptic neuron and increasing release of these monoamines into the extraneuronal space of the prefrontal cortex. Stimulant medications, like lisdexamfetamine, are first-line therapies for ADHD.

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: The enrollee is requesting authorization and coverage for the medication, Vyvanse. The enrollee has a history of major depressive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder. The enrollee reported concerns of binge eating over the last two months with an eight-pound weight gain over the last month. She reported increased stress, and increased symptoms of anxiety, depression, and attention deficit hyperactivity disorder. The enrollee requested a medication that would help to curb her excessive hunger. Her provider prescribed Vyvanse to control attention deficit hyperactivity disorder and binge-eating symptoms. The record indicates the enrollee stopped taking Ritalin, as it was not controlling her symptoms.

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