Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe atopic dermatitis. 
Treatment: Dupixent. 

The insurer denied the Dupixent. 
The determination is overturned. 

The patient has moderate to severe atopic dermatitis. The patient is currently awaiting a liver transplant (associated with biliary atresia and suffers from pruritus related to his severe cholestasis and his eczema (the patient has significantly elevated eosinophils). An Orthotopic Liver Transplantation failed because of a hepatic artery thrombosis with recurring biliary strictures, and has an external biliary drain placement. The patient is on oral hydroxyzine, omeprazole, levofloxacin, tacrolimus, and ursodiol. 
At a clinic visit, it was noted that the patient had jaundice, numerous hyperpigmented papules and heme-crusted excoriations, and lichenifications throughout the body, as well as allergic shiners. Eczematous patches were noted in the antecubital fossae, around the hairline, neck, and ankles. The patient was started on topical 0.1% triamcinolone ointment and Narrowband ultraviolet band (UVB) light therapy. High-potency topical steroids have been avoided due to provider concerns of the risk of systemic absorption. Dupilumab (Dupixent) was also started, and a prior authorization request sent to the patient's health plan. 

The medical necessity of Dupixent is under review. 

This patient's has a very complicated clinical scenario. The patient's atopic dermatitis is a very extensive and life-altering case, and the use of more potent topical steroids across his entire body is neither medically appropriate nor likely to be of clinical benefit. For a very large involved surface area such as this patient, topical triamcinolone is the normal strength of topical steroids and no more. Topical tacrolimus is the ideal "go-to" topical medication for this patient, and is the only topical nonsteroidal medication that is Food and Drug Administration (FDA)-approved for moderate to severe atopic dermatitis (Eucrisa, Elidel, and Opzelura are all the only FDA-approved for mild to moderate atopic dermatitis), and has not been used to date; however, with the patient on oral tacrolimus, the use of topical tacrolimus is much more likely than not to result in treatment failure. The patient is also on ursodiol to bind any bile salts to reduce pruritus, but this has not proven sufficient for the patient's liver-disease-induced jaundice and pruritus. 
The patient's treatment options require systemic therapy, but the use of traditional oral/systemic agents are all contraindicated because of the patient's severe hepatic disease, leaving only light therapy and Dupixent as literature-supported [1-4] viable agents. 

Were the patient to have insignificant atopic disease of the head, scalp, and neck, then phototherapy alone would suffice for this patient's systemic treatment, but such is not the case at this time (phototherapy alone for the sensitive areas of the head and neck and scalp is not medically appropriate). Although clinical trials are under way for the use of Dupixent in the treatment of hepatic pruritus [8], enough literature has been published [5-7] to support the medically necessary use of Dupixent for this particular patient at this particular time. 

Based on this patient's liver disease, and the significant atopic disease of the head, scalp, and neck (which is not appropriate for light therapy treatment alone), then phototherapy alone would suffice for this patient's systemic treatment, but such is not the case at this time. Although clinical trials are under way for the use of Dupixent in the treatment of hepatic pruritus [8], enough literature has been published [5-7] to support the medically necessary use of Dupixent for this particular patient at this particular time.
Therefore, for this patient's clinical clinical scenario, Dupixent is now medically necessary.