Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Jornay PM 20MG (milligrams) ER (extended release) Capsule
The insurer denied: Jornay PM 20MG (milligrams) ER (extended release) Capsule
The denial is upheld

The patient is an adult female. She has diagnoses of ADHD (attention deficit hyperactivity disorder), Bipolar II disorder, and anxiety disorder, unspecified. She has failed Adderall XR (extended release) for ADHD (attention deficit hyperactivity disorder). Methylphenidate ER (extended release) has been prescribed at various doses with little effect. She was not prescribed immediate release stimulant due to bipolar disorder. Methylphenidate LA (extended release) was prescribed in the past by former provider with poor effect. The request for Jornay PM (methylphenidate hydrochloride) was denied coverage by the health plan, as they note that she must try methylphenidate extended release, dexmethylphenidate extended release, and the doctor must provide clinical documentation that she met the condition above. The denial is being appealed.

The treatment with Jornay PM is not medically necessary.

The patient has failed Adderall XR (extended release) for ADHD (attention deficit hyperactivity disorder). Methylphenidate ER (extended release) has been prescribed at various doses with little effect. She was not prescribed immediate release stimulant due to bipolar disorder. Methylphenidate LA (extended release) was prescribed in the past by a former provider with poor effect.
While the patient has tried and failed methylphenidate extended release, she is not documented to have tried and failed dexmethylphenidate extended release, nor is she documented to have any contraindications to this medication. Having the patient trial dexmethylphenidate extended release before Jornay PM (methylphenidate hydrochloride) is reasonable and consistent with the standard of care. Dexmethylphenidate extended release would reasonably be expected to be at least as efficacious as the requested medication and would not be expected to jeopardize the patient's health.