Alopecia Areata 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

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Xeljanz XR tablets. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Alopecia areata is a chronic medical condition associated with autoimmune-mediated hair loss. When alopecia areata persists over time without adequate treatment, permanent hair loss may ensue, leading to considerable psychosocial distress. While historically treated with intralesional steroids, contact immunotherapy, oral steroids, cyclosporine, and methotrexate, such treatments had limited efficacy. Current medical literature offers a wealth of evidence pointing to the efficacy of oral systemic Janus kinase (JAK) inhibitors.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Opzelura 1.5% cream. The records indicate that this patient has a history of breast cancer and alopecia areata. The provider reports that the patient demonstrated an incomplete response to treatment with intralesional high-dose triamcinolone (ILTAC). The patient’s provider has recommended treatment with Opzelura. Given the patient’s history of cancer, treatment with oral or systemic Janus kinase (JAK) inhibitors is contraindicated, as indicated by the patient’s provider. As noted in the medical literature, alopecia areata is an autoimmune medical condition that can have a negative impact on a patient’s quality of life. The U.S. Food and Drug Administration (FDA) has approved Opzelura for the treatment of adult patients with severe alopecia areata.

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