Skin Treatment 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).

A 45-year-old female enrollee has requested authorization and coverage for the medication Taltz. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s plaque psoriasis. A review of the record indicates that the enrollee has been diagnosed with plaque psoriasis. The records reflect that the enrollee has a history of joint pain. The records indicate that the enrollee has tried and failed various treatments including methotrexate, clobetasol, Kenalog, and Nizoral shampoo. The enrollee has also tried Humira, and Stelara. The submitted records reflect that the enrollee has started treatment with Taltz. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities.

Where the denial was upheld

The enrollee is requesting authorization and coverage for the medication, Siliq 210 mg/1.5 ml. The enrollee has a 35-year history of psoriasis and of Hepatitis B-positive serology. He is being followed by a hepatologist and takes lamivudine, 150mg, as prophylaxis while on biologic therapy. The psoriasis is present on fifteen percent of his body surface area (BSA). He has large erythematous patches with silvery scales on his lower extremities. His fingernails show irregular pitting. He was treated with Humira for twenty months, but the provider documents a failed response to this treatment. The record indicates the enrollee has also failed treatment with topical steroids, phototherapy, Chinese medicine, acitretin and cyclosporine. Given the lack of positive response to previous medications, treatment choice has been taken into careful consideration by the provider.

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.

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