Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque psoriasis.

Treatment: Skyrizi.

The insurer denied coverage for the Pre-Service request for Skyrizi for the Treatment of Psoriasis.

The denial is upheld.

This is a female patient with plaque psoriasis affecting 70% body surface area (BSA).  The patient has failed topical steroids.  The request is for Skyrizi.

According to the 2018 American College of Rheumatology and National Psoriasis Foundation guidelines Phototherapy and oral agents for psoriasis [i.e., acitretin, cyclosporine, and methotrexate (MTX)] may be used first-line in various clinical situations.  Acitretin would not be a suitable choice given the patient's age.  However, cyclosporine may be effective long-term, but is normally reserved for intermittent use (up to 12 weeks) to control a flare so the patient can transition to another drug for long-term maintenance.  When used intermittently, a course of cyclosporine can induce an average decrease of more than 75% in psoriasis severity.  MTX is considered a first-line systemic agent for plaque psoriasis that may be used continuously for many years or decades with durable benefits.  The patient does not have a history of skin cancer or elevated liver function tests (LFTs) or liver disease or uncontrolled hypertension.  The provided documentation does not indicate the patient is currently pregnant, nursing, or actively family planning.  Phototherapy is certainly a viable option particularly when prescribed by any board-certified Dermatologist who is well-versed in this conventional treatment.  With regard to the use in patients with varying skin types, the most recent guidelines outline the methods to be used when phototherapy is selected for treatment. Medical necessity for Skyrizi has not been established.      

Per Wong et al. (2013), "Phototherapy is one of the most efficacious treatment options for psoriasis.  New, emerging studies are beginning to define the biologic mechanisms by which phototherapy improves psoriasis.  Phototherapy acts through a combination of pathways to confer therapeutic benefits in psoriasis, and these different modalities may help explain its particular usefulness in treating this cutaneous disease."

Per Racz et al. (2015), "Phototherapy is a first-line option for the treatment of moderate to severe psoriasis.  Systematic reviews indicate near comparable efficacy of the different forms of phototherapy.  Localized phototherapy can be an adjunctive treatment of recalcitrant plaques during systemic treatment of psoriasis...

Per Colombo et al. (2013), "Cyclosporine A (CsA) is one of the most effective systemic drugs available for the treatment of psoriasis, as evidenced by the results of several randomized studies and by a prolonged experience in dermatological setting.  In clinical practice, CsA is usually used for the induction of psoriasis remission at a daily dose included in the range of 2.55 mg/kg [milligrams per kilogram] and with intermittent short-term regimens, lasting on average 36 months."

Up to Date states regarding cyclosporine for psoriasis: "The use of cyclosporine in psoriasis is based upon multiple studies supporting its status as a highly and rapidly effective treatment [78,104-106]..."

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for the Pre-Service request for Skyrizi for the Treatment of Psoriasis is not substantiated.  The insurer's denial is upheld.