Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Ilumya
The insurer denied coverage for Ilumya.
The denial is upheld. 

This is a male patient with a diagnosis of psoriasis affecting his trunk and extremities.  The patient has tried and failed topical medications. The patient has a history of depression. The request is for Ilumya 100 milligrams (mg). The health plan requires for preferred cyclosporine or methotrexate to be tried and failed, or contraindication. The prescriber is concerned of naproxen interference with these preferred medications.

As per Choi et al. (2017), "Psoriasis is a chronic inflammatory disease. In the treatment of psoriasis, cyclosporine is a commonly prescribed systemic agent. However, long-term use of cyclosporine is not recommended because of side effects such as nephrotoxicity or hypertension." Thus, the use of cyclosporine may be contraindicated in the setting of using naproxen and the increased risk for nephrotoxicity. However, this is not the case for methotrexate. According to Martin et al. (2019), methotrexate is an effective drug against psoriasis, and while this use of drug is contraindicated in patients with alcoholism, chronic liver disease, hematologic disease, and/or known hypersensitivity to methotrexate, it is not contraindicated for patients who are at risk for abnormal renal function.  

Literature review, such as Armstrong and Read (2020) also indicates that methotrexate is an effective drug against plaque psoriasis, which is the most common variant of psoriasis. Armstrong and Read (2020) states that "The American Academy of Dermatology-National Psoriasis Foundation guidelines recommend biologics as an option for first-line treatment of moderate to severe plaque psoriasis because of their efficacy in treating it and acceptable safety profiles [and oral]...reatments include traditional agents such as methotrexate, acitretin, cyclosporine, and the advanced small molecule apremilast, which is a phosphodiesterase 4 inhibitor. The most commonly prescribed light therapy used to treat plaque psoriasis is narrowband UV-B [Ultraviolet B] phototherapy."                               

Based on the review of the medical record and literature, Ilumya is not considered medically necessary. While the patient has tried and failed topical medication for his treatment of psoriasis, the patient has not tried and failed any of the insurer's preferred biologic agents, such as methotrexate. There are no contraindications indicated for the use of methotrexate for this patient. The patient does not have any documentation of alcohol issue, liver/hematologic conditions, or hypersensitivity to methotrexate that would make the use of this preferred medication contraindicated. The literature supports the use of the preferred medication, methotrexate for the treatment of this patient's psoriasis. Therefore, Ilumya is not considered medically necessary for this patient.
                          
The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Ilumya should be upheld. The medical necessity is not substantiated.