Ankylosing Spondylitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rinvoq 15 mg ER tablets. The records provided for review document that this patient has a documented history of both ankylosing spondylitis and atopic dermatitis with involvement of 10% body surface area (BSA). Per review of the chart notes and an undated letter from the provider, the patient has been treated with and failed Taltz and Cosentyx. The patient is currently being treated with sulfasalazine for ankylosing spondylitis. The provider’s notes state that the patient has also tried and failed treatment with fluocinonide ointment, tacrolimus, triamcinolone ointment, and betamethasone. Given the patient’s concurrent diagnoses of both ankylosing spondylitis and atopic dermatitis, it is appropriate for the patient to be treated with Rinvoq, which is U.S.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient with a diagnosis of optic neuritis and human leukocyte antigen (HLA)-B27 positive ankylosing spondylitis (AS) has requested authorization and coverage for Taltz auto-injector. In this case, the patient has been diagnosed with positive antiphospholipid antibodies as well as a demyelinating condition, optic neuritis. The patient has also been referred to neurology to undergo an evaluation for multiple sclerosis, which is another demyelinating disorder. The records indicate that the patient tried and failed to respond to treatment with Cosentyx. Both Enbrel and Humira are tumor necrosis factor inhibitors (TNFi) and are not recommended for patients with demyelinating conditions, as they are associated with new onset or exacerbation of demyelinating disorders.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar Gel 80 unit/mL-5mL injection.Findings: The physician reviewer found that there is a paucity of data in the current medical literature supporting the use of H.P. Acthar Gel for the treatment of ankylosing spondylitis. In adults with active ankylosing spondylitis despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), Ward and colleagues recommend treatment with tumor necrosis factor inhibitors (TNFi), and with sulfasalazine, methotrexate, or tofacitinib when TNFi are not available. The authors further recommend physical therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for diclofenac sodium gel 3%. Van der Heijde and colleagues describe the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line intervention for ankylosing spondylitis. However, the authors do not mention topical NSAIDs specifically as a treatment option. In a study reviewing the use of diclofenac gel for acute musculoskeletal conditions, Wade and colleagues concluded that both ibuprofen/levomenthol and diclofenac gels provided superior global pain relief compared with ibuprofen gel, with a shorter median time to significant pain relief. In this case, the patient has a diagnosis of ankylosing spondylitis.

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