Psoriatic Arthritis denials in California external review
In the California DMHC record, independent physician reviewers decided 105 published external-review cases involving psoriatic arthritisand overturned the plan’s denial in 57.1%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for psoriatic arthritis
| Treatment | Decisions | Overturned |
|---|---|---|
| Otezla | 26 | 46.2% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 99 | 59.6% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 6 | 16.7% |
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 requested authorization and coverage for Humira. Psoriasis is a chronic, immune-mediated dermatological disorder characterized by an accelerated hyperproliferation of keratinocytes leading to the formation of erythematous plaques that can affect any part of the body. Some patients with psoriasis develop psoriatic arthritis. The treatment options for moderate-to-severe plaque psoriasis include topical therapies such as high-potency corticosteroids, vitamin D analogs, topical retinoids, and calcineurin inhibitors. Phototherapy options include narrowband ultraviolet B (UVB), psoralen ultraviolet A (PUVA), and excimer laser. Systemic treatments involve immunosuppressants and biological therapies.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Hydrocodone-Acetaminophen (Norco) 10-325mg tablets, quantity of 120 tablets per month, taken as one (1) tablet by mouth every 6 hours as needed.Standard therapy for rheumatoid arthritis/psoriatic arthritis includes the use of biologic drugs and DMARDs which are immunosuppressive therapies and carry the risk for infection. Due to a history of the left knee prosthetic joint infection, the patient has chosen to avoid biologic drugs and other DMARDs and is currently on hydrocodone-acetaminophen, which is an opiate, a controlled substance, to control chronic joint pain.Opioid pain medication use presents serious risks, including overdose and opioid use disorder.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel.Findings: The physician reviewer found that American College of Rheumatology guideline on the treatment of psoriatic arthritis notes, “In treatment-naive patients with active psoriatic arthritis (PsA), a tumor necrosis factor inhibitor (TNFi) biologic agent is recommended over an oral small molecule (OSM) as a first-line option. OSMs may be used instead of a TNFi biologic in patients without severe PsA and without severe psoriasis, those who prefer an oral drug instead of parenteral therapy, or those with contraindications to TNFi treatment, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 psoriatic arthritis, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY