Apremilast denials: what the review data shows

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (generic form apremilast) 30 mg tablets. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus.

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 is requesting authorization and coverage for Otezla. The enrollee has psoriasis affecting 10% of body surface area (BSA) including the scalp, chest, right forearm and forehead. Her dermatologist indicates the enrollee has tried and failed Lidex, Clobetasol, Calcipotriene, Enstilar, Mometasone, and multiple over-the-counter topicals. Biologics, such as Humira, Enbrel, Stelara, Simponi, and others have been avoided due to their immunosuppressive properties and side effects. Phototherapy is contraindicated due to the sensitive location of the psoriasis. Systemic disease-modifying anti-rheumatic drugs (DMARDs) have been avoided, as well, due to a history of anxiety and her childbearing age.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Apremilastwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.