Alopecia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested the medication, tofacitinib, (Xeljanz) for alopecia areata. Her dermatologist noted she developed diffuse and rapid shedding of scalp hair late last year. Her hair loss progressed despite steroid injections, prednisone, clobetasol propionate, ketoconazole shampoo, Rogaine, iron, and biotin supplements. Her dermatologist noted significant shedding and loss bitemporally; consistent with severe and progressive alopecia areata. She was prescribed tofacitinib and has noticed some hair growth to her scalp and stability of her hair loss. Her dermatologist indicates the patient will need to remain on the medication for at least six to nine months to realize its full effect; a positive result will necessitate long-term use of the medication.

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for Dupixent (dupilumab subcutaneous solution pen-injector 300 mg/2 mL). Findings: The physician reviewer found that alopecia areata is a common form of immune-mediated alopecia and that current treatment options mostly include non-specific broad immunosuppressants that are administered either locally or systemically, with first-line therapies involving the use of intralesional and topical steroids. However, such therapies are only approved for short-term use due to side effects. The authors further note that immunosuppressive agents such as methotrexate, cyclosporine, and azathioprine lack adequate evidence from randomized controlled studies to support their use and therefore tend to require very close patient follow-up due to potentially severe immunosuppression that may result.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Opzelura 1.5% cream. Frontal fibrosing alopecia (FFA) is a lymphocytic cicatricial alopecia. Other lymphocytic cicatricial alopecia include lichen planopilaris, central centrifugal alopecia, and chronic cutaneous lupus erythematosus. FFA is relatively uncommon and there are no treatments approved by government regulators this condition. Due to its scarring nature, it is important to treat this condition to avoid permanent damage due to scarring. There have been several small studies of various agents used for the treatment of lymphocytic cicatricial alopecia, including topical steroids and calcineurin inhibitors, oral hydroxychloroquine, oral dutasteride, and intralesional steroids.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for laboratory test (CPT 82725) for their medical condition of hair loss. Findings: The physician reviewer found that Hair loss is common as women get older. In a peer-reviewed article that patients presenting with hair loss should be screened by medical history, dietary history and physical examination for risk factors for nutrient deficiency. If warranted, laboratory studies may be performed. In patients with no risk factors, further laboratory evaluation searching for nutritional deficiencies is not recommended. For patients with nutritional deficiencies, these deficiencies should be corrected. Further research is required to determine whether any benefit exists for nutrient supplementation in the absence of documented deficiency. In this case, the patient has a history of chronic hair loss.

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