Atopic Dermatitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis (AD). The patient reported a body and facial rash. She has been treated with doxycycline, topical steroids, including hydrocortisone and triamcinolone, and a calcineurin inhibitor Elidel. The provider noted that the patient has a long-standing history of a facial rash. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted that the patient has failed treatment with hydrocortisone, vitamin E, and Aquaphor. Physical examination findings included a well demarcated scaly plaque on the dorsal hand and scaly patches around the eyes. A biopsy was performed and revealed vesicular spongiotic dermatitis. The differential diagnosis was noted to be either allergic contact dermatitis, atopic dermatitis, or other spongiotic diseases.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis and molluscum contagiosum. The provider noted that the patient’s eczema was unchanged since the last visit, with a current flare on the face and eyelids. The patient has been treated with phototherapy, tacrolimus, triamcinolone, ketoconazole shampoo, and fluocinolone. Physical examination findings included erythematous papules on the left chest, left abdomen, neck, and left arm. Many erythematous scaly plaques were noted on the arms and legs. The patient’s parent has requested authorization and coverage for Dupixent 400 mg subcutaneously on day one and 200 mg every two weeks thereafter. The Health Plan denied the request and reported that the requested medication regimen is not medically necessary for the treatment of this patient.

Where the denial was upheld

Findings: The physician reviewer found that The patient has requested authorization and coverage for Adbry solution prefilled syringe 150 mg/mL. The U.S. Food and Drug Administration (FDA) has approved Adbry for the treatment of moderate-to-severe atopic dermatitis in adult patients whose disease is not adequately controlled with topical prescription therapies. A recent consensus article on atopic dermatitis experts defined moderate-to-severe atopic dermatitis as greater than 10% body surface area (BSA) involvement and/or involvement of highly visible areas or those important for function and significantly impaired quality of life. The records document that this patient has moderate-to-severe atopic dermatitis given involvement of the face and involvement of the trunk. Several recent randomized clinical trials have shown the efficacy of Adbry in treating atopic dermatitis.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication, Dupixent. The enrollee has eczematous dermatitis affecting 20% of his body surface area (BSA). Currently he is using betamethasone dipropionate 0.05% ointment and over-the-counter Lamisil cream on his feet. At an office visit, the enrollee’s rash had recently spread to his trunk, legs, and arms. It itched all day and worsened after narrowband ultraviolet B (nbUVB) rays. The enrollee was not a candidate for methotrexate. It was recommended the enrollee stop nbUVB, continue clobetasol 0.05% ointment and start Dupixent (dupilumab).

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