What is "sufficient documentation" for an ADD medication?

August 17, 2014 1:06 PM

I've been taking Adderall XR for about a half a year, and it has made a tremendous difference in my life. The med, however, was recently put on the Prior Authorization list - which means that I now need to receive approval from my insurance before they cover it. My doc submitted an application, which I just found out was denied on the grounds that I don't have sufficient documentation of ADD. I took a test with my doc, and was denied again. What exactly do they want from me?

The first rejection document I received states that anyone 18 and older who starts on a stimulant needs an ADHD screening before starting on the medication. I had had a screening back in college, but that was many years ago and I couldn't find it - so I took a short test with my psych. She handed me a questionnaire, I filled it out, then she looked at it and said "yup, you have ADD." It was pretty bare-bones. I was denied again.

(The test was the ASRS, found on this site: http://www.help4adhd.org/documents/adultadhdselfreportscale-asrs-v1-1.pdf)

I called to ask and their answer was very noncommittal - along the lines of "Well, we can't say what kind of documentation you would need that might help, anything else would certainly help but the PA request could go either way..."

I get the feeling that my insurance just doesn't want to pay for stims. My psych was pretty dejected as well, and seems to want to give up. I can go on without the med, but without it I'm back to being my usual head-in-the-clouds self who can't focus on any one thing a a time. Its made such a positive impact on my life, and I'd like to get back on if possible. So, I'm wondering... what else could they want from me? Maybe a more comprehensive test? If so, would I ask my psych for it, or if not where would I take it? Is there another solution that I might be missing?

PS: I am planning on switching from Adderall XR to Vyvanse. Also, I was taking a booster of IR Adderall in the afternoon - combined, a daily total of 25mg.

posted by CottonCandyCapers to Health & Fitness (19 answers total)

They are probably just fucking with you, but a comprehensive neuropsychological battery from a clinical psychologist or other professional licensed to provided comprehensive neuropsychological testing (this person cannot be your treating therapist for talk therapy) would do the trick for ADHD diagnosis. Your psychiatrist should be able to refer you to someone who can provide those services.

Caveats: I had to pay out of pocket for my last one, and it was around $450, and required 6-7 hours of testing over the course of a couple of appointments. I also had to get my parents to fill out forms about me as a kid.

The professional who administers the test, if you do meet the criteria, can also be authorized to fill out the paperwork for prior authorization, and attach a letter summarizing the battery.

Moreover, then your insurance company has two separate professionals telling them to get stuffed, and they're more likely to back down.

You can also document through your prescribing psychiatrist any non-stimulant medication options (bupropion and atomoxetine are the two I can think of off-hand) you've tried that did not mitigate your ADHD symptoms, which also helps.
posted by Uniformitarianism Now! at 2:05 PM on August 17, 2014

Would letters from and/or tests from the perspective of friends, family, coworkers help? Something along the lines of "About 6 months ago there was a REMARKABLE TRANSFORMATION..."
posted by AllieTessKipp at 3:01 PM on August 17, 2014

You could try appealing the denial to your State Board of Managed Health care, as it's called here in California. It's not clear where you live, but it's likely that there's a state body of some kind that regulates the insurance industry - complaints filed with them can have a remarkable effect sometimes.
posted by jasper411 at 3:13 PM on August 17, 2014

I called to ask and their answer was very noncommittal - along the lines of "Well, we can't say what kind of documentation you would need that might help, anything else would certainly help but the PA request could go either way..."

Sounds like your insurer is, essentially, trying to weasel out of paying for Adderall by setting an invisible bar for you to jump.
posted by Thorzdad at 3:19 PM on August 17, 2014 [3 favorites]

For an expensive RA treatment that my new insurance twice denied for prior authorization, my doctor ended up setting up a "doctor-to-doctor" phone call with one of the doctors on staff at the insurance company who helps decide what should be approved or denied. This worked wonders in getting me approved. You might want to check if your insurance company has a similar feature and ask if you can set up a direct link between what your doctor recommends for you and what they might be willing to pay for.
posted by Merinda at 3:38 PM on August 17, 2014

It's totally your insurer trying to weasel out, but that might not be all it is.

Around here (which is not around there; YMMV), an adult diagnosis of ADHD requires (well, probably not requires, but is supposed to be supported by) evidence of ADHD going back to childhood.

My elementary school report cards, containing detailed comments about behaviour, were quite sufficient to that end. Also there was a questionnaire for my mom, which might have been enough on its own.
posted by Sys Rq at 4:08 PM on August 17, 2014

To a large extent, insurers will get out of ~anything~ they can get out of paying for, and ADHD drugs are the easiest to sidestep since they are widely believed to be over-prescribed. If you can speak with what one of my psych's called "An ADHD specialist", that might help. They're considered to know the problem inside and out, and a diagnosis from one might carry more weight with your insurer.

I wish you great luck. As someone with adult-onset ADD (No "h" here), I can't get 95% of the psychs I've seen to even believe that I have it. If they could see what I'm like with and without, I believe they'd have no doubts.
posted by Meep! Eek! at 4:18 PM on August 17, 2014 [3 favorites]

I had to do a battery of tests (the short form MMPI among others) including material from people who knew me since childhood as mentioned above. It was about five hundred dollars. I too have a prior auth req for the drugs and that was the only way I could get it prescribed.
posted by winna at 4:28 PM on August 17, 2014 [1 favorite]

I should mention that my diagnosis is "combined type," and that is much easier to get approved. :—/
posted by Uniformitarianism Now! at 4:44 PM on August 17, 2014

I don't know anything about negotiating this, but your insurer not covering it is not necessarily a reason you have to stop taking it. You can always self-pay. It sucks, but it's a possibility.
posted by Sequence at 5:02 PM on August 17, 2014 [1 favorite]

I'd say go in with as much documentation as possible, and keep copies and records of who you speak to.

Bear in mind that it is not just you; this is happening for minors as well.
posted by Buttons Bellbottom at 5:10 PM on August 17, 2014

Diagnosis can include these 3 tests: Brown (Adult) ADD Scales, Barclay (Adult) ADHD Structured Interview, Minnesota Multiphasic Personality Inventory-2; they may be sufficient -- but not all necessary.
posted by lathrop at 5:38 PM on August 17, 2014

You need to have a psychologist test you. The GPs questionnaire won't cut it. You can thank all of the asshole college students abusing Adderall for the expense and hassle.
posted by Crotalus at 6:13 PM on August 17, 2014

Also, why Adderall XR? Regular Adderall is generic, and you can pay for it yourself no problem. You can make your own "XR" with a pill splitter if necessary.
posted by Crotalus at 6:14 PM on August 17, 2014

Also, why Adderall XR? Regular Adderall is

...super addictive. That's why XR.
posted by Sys Rq at 7:23 PM on August 17, 2014

Your insurer is just being a shitass. I got that same notice from my company and the prescription was filled the next day after a call from my neurologist. I've been seeing the same doctor for 6 years, though, so I might have more of a treatment history than you do.

And for anyone unaware, the difference between regular adderall and the XR version is vast and cannot be made on your own by cutting up the regular tabs, what a ridiculous suggestion.
posted by elizardbits at 11:12 PM on August 17, 2014 [3 favorites]

Also, why Adderall XR? Regular Adderall is generic.

And the XR is also available in generic form -- that's what I take.
posted by naturalog at 9:28 AM on August 18, 2014 [1 favorite]

Yeah, my XR is like five bucks.

For the love of heaven don't cut up regular adderall that is absurd.
posted by winna at 11:21 AM on August 18, 2014

Pretty much. "Cut up adderall to make XR" is pretty much on the line of, "Just do bumps of coke to focus!"

I had a shit time of trying to get treated, including some asshole doctor at County who assured me that all ADD is adequately diagnosed in minors, so that I'd been diagnosed as an adult meant it wasn't real, despite my test results. I'm still pissed at that fucko.

For me, what really helped was that my college did a screening clinic as part of a research project, so I got in — and they kept my records, so when I finally had insurance some five years later, I could get copies. Does your college do something similar?
posted by klangklangston at 5:37 PM on August 18, 2014