Alopecia Universalis denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested Olumiant once-daily tablets to treat the patient’s severe alopecia universalis. As noted in the medical literature, alopecia universalis is defined as the complete hair loss over the body due to immune-mediated hair inflammation. Patients with alopecia universalis experience higher rates of mood disorders due to the psychological stress created by the disease. Further, the patient’s quality of life is diminished due to her condition. Currently, there are limited treatments that are utilized successfully to treat extensive alopecia areata and alopecia universalis.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee who has a history of psoriatic arthritis and alopecia universalis.Findings: There is support in peer-reviewed medical literature as to the efficacy of the requested medication in this patient’s case. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata which includes hair loss in eyebrows, eyelashes and facial hair. Other autoimmune diseases are also linked with alopecia areata. In addition, treatment is challenging and aims at the regrowth of hair.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg, quantity of 60 per month. The American Academy of Dermatology (AAD) guidelines for management of patients with alopecia areata or alopecia universalis includes intralesional or systemic corticosteroids, topical corticosteroids with Minoxidil, immunotherapy such as diphenylcyclopropenone (DPCP), and phototherapies (Alkhalifah, et al.). Cyclosporine, methotrexate, and sulfasalazine are other potential treatment options. For adults with more than 50% scalp involvement, DPCP is the treatment of choice. In this case, the patient’s history of alopecia universalis has lasted for approximately eight years. The patient’s provider has recommended treatment with Xeljanz. However, Xeljanz is not U.S. Food and Drug Administration (FDA) approved for the treatment of alopecia universalis.

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