Plaque Psoriasis denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 46-year-old male with a history of chronic plaque type psoriasis who has recurrent psoriatic skin disease. He has tried standard therapies including topical Dovonex, topical retinoids and topical and intralesional corticosteroids with chronic exacerbations and incomplete clearance. The patient has requested authorization and coverage for excimer laser treatments. The Health Plan has denied coverage for the requested therapy on the basis it is considered investigational for treatment of the patient’s condition.Traditionally, psoriasis has been difficult to treat successfully. Some patients respond better to certain therapies than other patients. At present, there is no method to determine which therapy will be most effective for a particular patient.

A 45-year-old female enrollee has requested authorization and coverage for the medication Taltz. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s plaque psoriasis. A review of the record indicates that the enrollee has been diagnosed with plaque psoriasis. The records reflect that the enrollee has a history of joint pain. The records indicate that the enrollee has tried and failed various treatments including methotrexate, clobetasol, Kenalog, and Nizoral shampoo. The enrollee has also tried Humira, and Stelara. The submitted records reflect that the enrollee has started treatment with Taltz. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara injections for treatment of the enrollee who has a history of severe plaque psoriasis. Findings: The physician reviewer found that the documentation provided does not support the medical necessity for the requested medication in this clinical setting. Due to the location of the psoriatic plaques, phototherapy is also not practical as penetration of the ultraviolet light is difficult in those areas. Due to her age and child-bearing status, use of acitretin is also not recommended. The provider noted that due to the patient’s history of malignancy, the patient is precluded from methotrexate, cyclosporine and tumor necrosis factor (TNF) inhibitors. However, the medication requested is also an injectable biologic agent.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (apremilast) for treatment of her psoriasis. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient has a history of plaque psoriasis and concomitant hepatitis B infection, on therapy. The patient is not able to take methotrexate and cyclosporine due to presence of hepatitis B infection. She has already tried and failed therapy with acitretin due to intolerance and itching. Otezla is a newer medication that is not considered to be immunosuppressive. However, there is minimal data to suggest that Otezla is safe for those with hepatitis B.

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