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Obsessive-Compulsive Disorder Case Study

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A review of the records reveals the member to be a male child with a date of birth of 03/31/2007. The child has diagnoses of ADHD and Dyspraxia. His provider, Jose Foradada, MD has recommended Methylphenidate ER 27 mg Tab 30/30 for treatment of this member’s condition.

The carrier has denied coverage of Methylphenidate ER 27 mg Tab 30/30 as not medically necessary. There is a letter from the carrier to the member dated 03/04/2016, which states in part:

“The benefit requires coverage for the requested drug when medically necessary. However, the information submitted doesn’t meet Humana medical necessity guidelines for coverage. The member must meet the following criteria: previous treatment within the last twelve months, contraindication …show more content…
He has been under the care of pediatric neurologist, Jose Foradada, MD, for at least three years who had been prescribing the Daytrana patch. However, at present, there is a nationwide problem obtaining Daytrana from pharmacies due to a shortage in supply. Thus, the member’s treating neurologist prescribed the oral preparation (methyphenidate ER aka MPH ER), which is the same medication found in the Daytrana …show more content…
The Plan has denied coverage of the oral methylphenidate ER stating “Information submitted does not meet Humana’s medical necessity guidelines for coverage. Member must meet following criteria: Previous treatment within the past 12 months, contraindication or intolerance to brand Adderall XR and one other long acting stimulant (eg VYVANSE or MPH SR).”

The first issue is the Daytrana patch (methylphenidate aka MPH SR), which appears to have been covered by the member’s Plan is currently difficult to obtain due to a nationwide shortage. As a substitute, the oral methyphenidate ER (MPH ER) was prescribed because it is standard of care as the MPH SR or Vyvanse has very inconsistent efficacy and clinical response or reliability. In addition, since the member has a good response to the methylphenidate in patch form, it would not be recommended to change medication class to an amphetamine at this time.

In summary, the requested medication, methylphenidate ER is in the same class as the Daytrana patch, which yielded an excellent clinical response for this member, without adverse side effects and with good clinical

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