Otezla denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication Otezla. The enrollee has psoriasis over 30-40% of his body surface area (BSA). He has had psoriasis all over his body for many years. Prior treatments of various lotions have not demonstrated significant improvement. He was planning to start Otezla last year, but he had an elevated white blood cell (WBC) count and required further workup. After recent lab work, the PCP approved treatment with Otezla. The dermatology nurse practitioner (NP) reviewed the labs and noted the enrollee had elevated WBCs, neutrophils and eosinophils; which have been elevated for the last three years. An Otezla titration package was given to the enrollee. The NP notes the enrollee has tried and failed various treatments; including Enstilar and various other topicals.

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: An enrollee has requested authorization and coverage for the combination of Otezla (titration pack followed by 30mg twice a day) with Inflectra infusions.Findings: Two out of three physician reviewers found that the requested combination of Otezla (titration pack followed by 30mg twice a day) with Inflectra infusions is not likely to be more beneficial than any other available standard treatment for the patient’s medical condition.American College of Rheumatology/National Psoriasis Foundation guidelines state that in those patients with active psoriatic arthritis despite TNFi monotherapy, switching to a different TNFi biologic monotherapy is recommended over switching to IL-12/23i biologic, an IL-17i biologic, abatacept, or tofacitinib monotherapy or adding methotrexate to the current TNFi biologic.

Nature of Statutory Criteria/ Case Summary: According to the records, the enrollee went to the urgent care center complaining of psoriasis all over her body with the exception of her face, neck, and chest . She reported the sites had not improved, had flared and were itchy. It was noted her whole upper body had healed well and she had been applying betamethasone and calcipotriene to her legs. However, her legs were starting to become itchy and the physician noted scattered, small, psoriatic, annular, clustered plaques to her shins. This was a new flare due to stopping Otezla. It was recommended she continue utilizing Otezla and follow-up. According to a review of the record, there are effective, safe alternatives that have not been trialed.

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