Psoriasis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Cosentyx injectables 150 mg, two times subcutaneous on week 0, 1, 2, 3, and 4. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patient’s psoriatic arthritis and psoriasis. The submitted documentation supports the medical necessity of the requested medication regimen. The American College of Rheumatology does not currently have any national guidelines for the U.S. regarding the recommendations for the treatment of psoriatic arthritis (PsA).

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with psoriasis. Previously, the patient reported a rash on her arms, back, genital area, and scalp which had been present for three months. The provider noted psoriasiform plaques were present over the patient’s scalp, lower back, right thumb, and bilateral elbows. Otezla samples were provided to the patient. Later, the provider noted psoriasiform plaques on the patient’s scalp, low back, right thumb, and bilateral elbows had improved by 30% while taking Otezla. The provider noted that the patient is not a candidate for treatment with disease-modifying antirheumatic drugs (DMARDS) or phototherapy. The patient had failed treatment with betamethasone, mometasone, and Eucrisa. The provider also noted the patient showed improvement with no adverse effects after eight weeks of treatment with Otezla.

Where the denial was upheld

The enrollee is requesting authorization and coverage for the medication, Siliq 210 mg/1.5 ml. The enrollee has a 35-year history of psoriasis and of Hepatitis B-positive serology. He is being followed by a hepatologist and takes lamivudine, 150mg, as prophylaxis while on biologic therapy. The psoriasis is present on fifteen percent of his body surface area (BSA). He has large erythematous patches with silvery scales on his lower extremities. His fingernails show irregular pitting. He was treated with Humira for twenty months, but the provider documents a failed response to this treatment. The record indicates the enrollee has also failed treatment with topical steroids, phototherapy, Chinese medicine, acitretin and cyclosporine. Given the lack of positive response to previous medications, treatment choice has been taken into careful consideration by the provider.

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with psoriasis. The provider noted extensive plaque psoriasis to the patient’s scalp, trunk, groin, and extremities which was noted to be chronic and worsening with a body surface area of 20%. The Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form noted the patient had trialed and failed treatment with Stelara and topical steroids. The provider has recommended Cosentyx for the patient. The health plan has denied this request indicating that the requested medication Cosentyx is not medically necessary for the treatment of this patient. The submitted documentation does not support that the requested medication is medically necessary.

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