Stelara 90 Mg Every Four Weeks denials: what the review data shows
Independent reviewers have decided 12 published cases where an insurer denied Stelara 90 Mg Every Four Weeks — and they overturned the insurer 100% of the time. A denial for Stelara 90 Mg Every Four Weeks is a starting position, not a final answer.
Conditions behind stelara 90 mg every four weeks denials
| Category | Decisions | Overturned |
|---|---|---|
| Crohn's Disease | 9 | 100% |
| Ulcerative Colitis | 3 | 100% |
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara (ustekinumab) 90 mg from every four weeks. Current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. Sands and colleagues report in a double-blind, placebo-controlled trial of ustekinumab as induction and maintenance therapy for ulcerative colitis that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response. Kopylov and colleagues note that dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks.
Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Crohn’s disease. The provider noted that the patient had been treated with Remicade, Humira, Cimzia, Entyvio, and azathioprine. The provider noted the patient was status post small bowel resections and had failed treatment with Entyvio and Stelara 90 mg every eight weeks. The provider noted that the patient was taking Stelara 90 mg every four weeks. The patient reported that her symptoms, including diarrhea, had significantly improved. The patient has requested authorization and coverage for Stelara 90 mg every four weeks. The Health Plan denied the request and reported the requested medication regimen is not medically necessary for the treatment of this patient. At issue in this case is whether Stelara 90 mg every four weeks is medically necessary for the treatment of the patient’s medical condition.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Stelara 90 Mg Every Four Weekswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY