Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia. 
Treatment: Pharmacy/Prescription Drugs. 
The health plan denied the requested prescription drug (Xeljanz). 
The health plan's determination is upheld. 

This patient is a male with Alopecia Areata (AA). The patient has previously been treated with intralesional catalog. The provider requests Xeljanz. 

The health plan's determination regarding the proposed health service or treatment is upheld, in whole. 

According to the U.S. Department of Health & Humana Services, National Institutes of Health (NIH) and Genetic & Rare Diseases Information Center (GARD) (2017), "No therapy has been found to work for everyone who has alopecia universalis (AU) which makes managing AU challenging. Although multiple treatments have been explored, no therapy is currently approved by the United States Food and Drug Administration (FDA). Some promising therapies include: Diphenylcyclopropenone (DPCP), Squaric Acid Dibutylester (SADBE), photodynamic therapy, steroids, Cyclosporine in combination with Methylprednisolone (a steroid). There are several recent studies showing that a class of medication known as JAK (Janus Kinase) inhibitors, which includes Tofacitinib and Ruxolitinib, are effective in alopecia areata, including AU. However, JAK inhibitors have not yet been approved by the FDA for use in skin conditions." 

Furthermore, according to Kassira et al. (2017), "Management of AT (alopecia totalis) and AU can be challenging, and although multiple treatment modalities have been explored, no therapy is currently FDA-approved. This review focuses on the evidence for current treatment options for AT and AU. The PubMed database was searched from January 1, 2000, to September 1, 2016, for clinical trials, retrospective studies, and case reports of treatments for AT and AU. A total of 40 studies were retrieved and analyzed. Therapies studied for AT/AU included: topical immunotherapy, steroids, photodynamic therapy, immunosuppressive agents, TNFa inhibitors, and other therapies, such as Sulfasalazine, Bexarotene, JAK inhibitors, and Simvastatin/Ezetimibe. Although certain treatments showed significant hair regrowth, no treatment was completely effective. The most promising therapies with the highest quality data include Diphenylcyclopropenone, Squaric Acid Dibutylester, photodynamic therapy, steroids, and Cyclosporine in combination with Methylprednisolone. High-quality randomized-controlled trials with large sample sizes are lacking. Unified outcome guidelines are encouraged to facilitate the comparison of future studies." 

Per Ibrahim et al. (2017), "Tofacitinib citrate is a Janus Kinase 1/3 inhibitor approved for the treatment of rheumatoid arthritis, but it has recently been used to treat alopecia areata. To truly assess efficacy, therapeutic trials should continue in the clinical setting for a minimum of 4 months and potentially up to 1 year. Patients should be informed of the lack of durability of effects after the treatment is discontinued. Future studies, including those using other Janus kinase inhibitors, such as Tuxolitinib Phosphate, are needed and should continue to elucidate these medications' efficacy, safety, and durability in the treatment of AA."