Cosentyx 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 requested authorization and coverage for Cosentyx Sensoready 300 mg auto-injector weekly for five weeks then every four weeks. Systemic treatment of psoriasis is indicated when topical treatments fail to achieve sufficient control of disease. The U.S. Food and Drug Administration (FDA) has approved several systemic options for the treatment of patients with moderate-to-severe psoriasis including non-biologics and biologics. Per Armstrong and colleagues, the interleukin-17 (IL-17) inhibitors and interleukin-23 (IL-23) inhibitors have the best efficacy of all the biologics and have been found to be more effective than non-biologics for the treatment of patients with psoriasis. This patient’s clinic notes document that he was started on Skyrizi.

Where the denial was upheld

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx pens (secukinumab), start with loading dose of 300 mg every week for five weeks, then 300 mg every four weeks thereafter for maintenance dose.Findings: Two of the three physician reviewers found the requested Cosentyx pens (secukinumab), start with loading dose of 300 mg every week for five weeks, then 300 mg every four weeks thereafter for maintenance dose are not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. The current medical literature supporting the use for secukinumab for the treatment of hidradenitis suppurativa is limited to case reports of a few open label and retrospective studies without randomization or a control group.

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