Arbitrary medication denials leads to restriction of optimal treatment
In my periodic entries of insurance companies’ denial of ADHD medication dosing, I offer you this recent example.
A female in her late 20s treated for ADHD with a combination of Adderall XR and Strattera. Strattera adds a benefit for her executive function not optimized with Adderall XR. I carefully dosed the Strattera upward and suggested increase to 120 mg daily.
Well, the folks at BlueCross Northeastern Pennsylvania denied the dose “As per the FDA recommended dosing guidelines for Strattera in adults the maximum dose is 100 mg per day.” Correctly stated per the package insert for Strattera. “There are no data that support increased effectiveness at higher doses. Therefore medical necessity for 120 mg of Strattera per day has not been met.”
This last statement is a misrepresentation of the purpose of a drug package insert. In fact, the adult registration trial for Strattera submitted to the FDA lists the dose that was used as up to 120 mg daily. Registration trials are designed for the purpose of seeking drug approval for a specific disease state. This research DOES NOT answer the question “If the patient is suboptimally treated with x dose, will they improve further with a higher dose?” So the logic of their denial is a misrepresentation of research for the sole purpose of constricting treatment and conserving money, in my opinion.
Yet more damage is done with these letters. People reading these letters may think the doctor is over-dosing them and not considering safety issues. This is simply not true since safety data on medications are routinely undertaken at much higher doses. There was no unusual safety concern with Strattera at 120 mg daily in the adult registration trial.
It is unfortunate that I find myself blogging about the denial of medication authorizations for my patients who clearly need better outcomes from their medications. While these companies have set up appeal processes, this tends to administratively time consuming without any guarantee that the medical necessity and logic of the dose request will be reviewed with the patient’s interest in mind.
So, what can YOU do if this happens to you? Here are the steps:
1. Call the insurance company and respectfully explain why you need your medicine. If the person is unresponsive, ask to speak to supervisor. If you don’t get to speak to someone with authority, ask if the conversation is being recorded and tell them to “tag” the audio file so that the State Insurance Comissioner’s Office with be able to listen to the audio file. Now, write down the date and time.
2. File a complaint with your state insurance commissioner’s office. You can find the contact information online by searching “<your state> insurance commissioner office”. In your complaint, which should only be one page (no reads anymore), state your brief history of medication history and why it is necessary to have the new dosing authorized for coverage. Write that you spoke with the insurance on what date and time.
In my experience, more often than not, you’ll be getting your approval. However, no guarantees. Good luck.