Dupixent denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis (AD). The patient reported a body and facial rash. She has been treated with doxycycline, topical steroids, including hydrocortisone and triamcinolone, and a calcineurin inhibitor Elidel. The provider noted that the patient has a long-standing history of a facial rash. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted that the patient has failed treatment with hydrocortisone, vitamin E, and Aquaphor. Physical examination findings included a well demarcated scaly plaque on the dorsal hand and scaly patches around the eyes. A biopsy was performed and revealed vesicular spongiotic dermatitis. The differential diagnosis was noted to be either allergic contact dermatitis, atopic dermatitis, or other spongiotic diseases.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis and molluscum contagiosum. The provider noted that the patient’s eczema was unchanged since the last visit, with a current flare on the face and eyelids. The patient has been treated with phototherapy, tacrolimus, triamcinolone, ketoconazole shampoo, and fluocinolone. Physical examination findings included erythematous papules on the left chest, left abdomen, neck, and left arm. Many erythematous scaly plaques were noted on the arms and legs. The patient’s parent has requested authorization and coverage for Dupixent 400 mg subcutaneously on day one and 200 mg every two weeks thereafter. The Health Plan denied the request and reported that the requested medication regimen 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 the medication, Dupixent. Findings: The physician reviewer determined that the requested medication is not medically necessary for the treatment of the enrollee’s medical condition. The enrollee has a diagnosis of atopic dermatitis. He was seen in a dermatology office for eczema and dermatitis on his legs and upper body and Clobetasol cream was prescribed. Examination revealed atopic dermatitis with excoriated scaly plaques of the right arm, left supraclavicular, and right chest. Clobetasol with Cerave cream was continued and a prior authorization for Dupixent was requested. He was seen in follow up and atopic dermatitis on his full body with failed treatment with Doxycycline and Bactrim DS. Culture of the right leg showed heavy growth of Staphylococcus aureus with sensitivity to Bactrim and Augmentin.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with chronic rhinosinusitis. A sinus computed tomography (CT) scan showed mild mucosal thickening of the left maxillary sinus with opacification of the ostiomeatal complex. The patient reported facial pressure, nasal congestion and postnasal drip. The patient reported he has experienced symptoms for 15 years. The patient was status post sinus surgery two to three years prior. The records indicated that except for a tree allergy, allergy testing was negative. Per the documentation, a two- anda-half month course of allergy shots did not help the patient’s symptoms. The patient has requested authorization and coverage for Dupixent 300 mg/2 ml. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient.

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