Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis

Treatment: Otezla 10-20-30 milligram (mg) oral tablet starter dose pack as prescribed #55/28

The insurer denied coverage for Otezla 10-20-30 milligram (mg) oral tablet starter dose pack as prescribed #55/28.

The denial is overturned.

This is the case of a patient that has been diagnosed with psoriatic arthritis and psoriasis.
A rheumatology note dated indicated the patient had diffuse joint pain for many years. The patient's right foot was very painful. The patient had a bunionectomy in the past and has a history of low back bulging discs. The patient has right shoulder pain, feels dizzy, and has high blood pressure. The patient's past medical history states that the patient has attention deficit hyperactivity disorder (ADHD) and psoriasis. It was noted the patient was allergic to aspirin, which caused nosebleeds. A physical examination showed the patient to be in no acute distress. A musculoskeletal examination showed arthritic changes in the fingers with an assessment of multiple joint pain. X-rays were ordered.

A follow-up evaluation occurred with the chief complaint of joint pains. The patient's physical examination was unchanged. The patient had scalp psoriasis and features of psoriatic arthritis (PsA). Immunosuppressives were discussed.  Laboratory tests showed a normal comprehensive metabolic panel

A letter of denial was generated by the insurer for coverage of Otezla. The denial was on the basis that she has not failed disease modifying agents such as nonsteroidal anti-inflammatory agents.

An appealing communication indicated that the patient has long-standing severe psoriatic arthritis and has joint pain and swelling to the hands, back, neck, feet and shoulders, and difficulty walking. It was noted the patient has Swan neck deformities and scalp psoriasis. Disease modifying agents are contraindicated given the fact that the patient has hematological toxicity. The patient has a history of bleeding and extensive family history of cancer. It was noted the patient had bleeding on Tylenol and nonsteroidal anti-inflammatory agents.

The final adverse determination letter indicated that the final determination was a denial of the requested Otezla because there was no documentation of failure to respond to one disease modifying agent or nonsteroidal agent.

The request is for Otezla 10-20-30 milligrams (mg) oral tablet starter dose pack as prescribed (number) #55/28, which is under review.

The denial was based on the fact that there was no documentation of having tried and failed nonsteroidal anti-inflammatory agents. A letter of appeal certified that the patient has had trouble with nonsteroidal anti-inflammatory agents and Tylenol, which caused bleeding. The note also indicates that the patient had nosebleeds from aspirin. Given the history of toxicity in nonsteroidal agents, the requested Otezla 10-20-30 mg oral tablet starter dose pack as prescribed #55/28 is certified and is medically necessary.
                                            
Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Otezla 10-20-30 milligrams (mg) oral tablet starter dose pack as prescribed #55/28 is substantiated.