Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for the requested medication, Olumiant. The enrollee has tenosynovitis attributed to rheumatoid arthritis. The enrollee has tried and failed treatment with Enbrel, Orencia, Plaquenil, sulfasalazine, methotrexate, and Arava. An examination indicates discomfort due to musculoskeletal pain of the shoulders, hips, and knees with a pain score of seven. The enrollee had been taking Orencia subcutaneous injections weekly when her medication was changed to Olumiant, 2mg tablets, once a day. A follow-up visit indicated relief with the Olumiant. A diagnosis of inflammatory polyarthropathy was made and the plan was to continue Olumiant and add diclofenac sodium topical gel. The rheumatologist indicates the enrollees disease has worsened, and she has more difficulty self-injecting, which is another reason for prescribing Olumiant. Olumiant is a biologic medication, indicated for autoimmune inflammatory arthritis, specifically, rheumatoid arthritis. The medical literature describes baricitinib (Olumiant) as an oral medication that may have therapeutic value in patients with rheumatoid arthritis. A daily dose of baricitinib, 4 mg, was associated with clinical improvement at 12 weeks in patients with rheumatoid arthritis who did not respond well to disease-modifying anti-rheumatic drugs. Guidelines for the treatment of rheumatoid arthritis indicate it is optional to use another anti-tumor necrosis factor drug, such as Humira, in a patient who has failed one anti-tumor necrosis factor medication; in this case, Enbrel. The alternative is to use another biologic, such as Orencia, which was used for this enrollee, or a Janus kinase inhibitor. The medical literature indicates Olumiant is associated with increased risk of infections, malignancy and thromboembolism.  The record indicates the enrollee has a diagnosis of tenosynovitis. Olumiant is not medically indicated without documentation of rheumatoid arthritis as being the etiology of the tenosynovitis, with objective findings on examination or imaging of inflammation of the tendon lining. There is insufficient evidence in the record to support findings of active inflammation for this enrollee. The provider cites the enrollees difficulty with self-injections. However, there are insufficient findings in the record, which would affect her manual ability to self-inject. At the visit when Orencia was stopped, it was due to lack of efficacy. No injection problem was noted. At another visit, wrist pain was indicated, but no hand deformity or extensive hand involvement was documented that would prevent self-injection. There is no documentation noting self-injection had been a problem with Orencia or Enbrel.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.