Hidradenitis Suppurativa denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 45-year-old male with longstanding nodulocystic acne and hidradenitis suppurativa. He has previously been prescribed numerous antibiotics without successful resolution of his symptoms. Accutane provided some benefit but had to be discontinued due to hypertriglyceridemia in spite of the concurrent administration of lipid lowering agents. Enbrel therapy has been recommended for the patient, but The Health Plan denied coverage due to the investigational nature of the therapy.The patient and his provider are without significant options other than tumor necrosis factor (TNF) inhibitors at this point in his treatment. The preliminary evidence does support the use of this therapy for the treatment of hidradenitis suppurativa, and it is a reasonable approach at this juncture.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Xeljanz extended release 11 mg tablets and (2) Humira injector pen 40 mg/0.4 mL subcutaneous kit. Findings: The physician reviewer found that there are few therapies for the treatment of moderate-to-severe hidradenitis suppurativa (HS), Humira has been studied and approved by the U.S. Food and Drug Administration (FDA) for this indication. While the FDA recommended dosage is 40 mg weekly, Bouguen and colleagues note that adalimumab 80 mg weekly is well-tolerated and effective in the treatment of Crohn’s disease, indicating that 80 mg weekly is a safe dosage. Current medical literature includes several recently completed and ongoing clinical trials on the use of Janus kinase (JAK) inhibition for the treatment of HS.

Where the denial was upheld

An enrollee has requested authorization and coverage for a panniculectomy.According to the American Society of Plastic Surgeons, a panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient’s appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure.

A 39-year-old female has requested laser hair removal for treatment of her pseudofolliculitis and hidradenitis suppurativa. Findings: Two physician reviewers found that this patient has insulin dependent diabetes mellitus and has had a diagnosis of hidradenitis supportiva and pseudofolliculitis for four years. The records indicate the patient has been treated with incision and drainage on multiple occasions and oral antibiotics. The abscesses cause her sugars to elevate. She reportedly experienced a serum sickness like reaction to one of the antibiotics. Her provider has recommended treatment with laser hair removal to give her some relief of this chronic disease. Hidradenitis supportiva is a chronic debilitating disease without any known long-term effective cure. Treatment modalities are largely anecdotal and not based on double blind placebo controlled studies.

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