Psoriasis Vulgaris denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that: Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Tremfya injection for the stated condition of psoriasis vulgaris. Current medical literature indicates that systemic treatment of psoriasis is indicated when, as in this case, topical treatments or do not achieve sufficient control of the disease. There are several FDA approved systemic options for moderate-severe psoriasis such as non-biologics including methotrexate, cyclosporine, acitretin, and apremilast (Otezla), and biologics including TNF-alpha inhibitors, IL-17 pathway inhibitors, IL-12/23 inhibitors (Stelara), and IL-23 inhibitors. A review of differing approaches indicate that non-biologics have a poorer efficacy than biologics in the treatment of psoriasis.

The patient has been diagnosed with psoriasis vulgaris. In the Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted clobetasol, lidex foam, and betamethasone had provided mild control of the patient’s psoriasis. The provider noted that the patient had a history of skin cancer and breast cancer. The provider noted biologic injectables would compromise the patient’s immune system. Per the records, the patient has been taking Otezla, with decreased flares. the records indicated that the patient had been treated with photodynamic therapy for her face. The patient has requested authorization and coverage for Otezla tablets. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication Otezla. The enrollee has psoriasis vulgaris. She has pink papules with collarette located on the scalp. She has used Clobetasol, 0.05% scalp solution, and Derma-Smoothe/FS Scalp oil, 0.01% but these treatments have failed. Psoriasis is affecting eight percent of her body surface area (BSA), including the scalp. The dermatologist is requesting authorization of Otezla. The dermatologist notes Otezla is Food and Drug Administration (FDA)-approved for the treatment of persons with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Additionally, the FDA does not require a trial of any specific medications prior to Otezla initiation.

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Tremfya 100mg/ml injections. According to the medical record, the enrollee was initially seen by a dermatologist complaining of a rash on his body that was not responding to Benadryl or cortisone cream. He was diagnosed with psoriasis vulgaris with 50% of body surface area involvement including his arms, legs, feet, back, and buttocks. He was not a good candidate for Methotrexate or Soriatane due to their effects on the liver. In addition, the enrollee is unable to go to the office for ultraviolet therapy. A Quantiferon TB gold test was negative. He was given a sample injection of Tremfya with plans for his next injection in four weeks. He also used topical steroids. At follow-up, his psoriasis has improved to one percent body surface area involvement.

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