Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1:  The patient is a 45-year-old male with longstanding nodulocystic acne and hidradenitis suppurativa. He has previously been prescribed numerous antibiotics without successful resolution of his symptoms. Accutane provided some benefit but had to be discontinued due to hypertriglyceridemia in spite of the concurrent administration of lipid lowering agents. Enbrel therapy has been recommended for the patient, but The Health Plan denied coverage due to the investigational nature of the therapy.The patient and his provider are without significant options other than tumor necrosis factor (TNF) inhibitors at this point in his treatment.  The preliminary evidence does support the use of this therapy for the treatment of hidradenitis suppurativa, and it is a reasonable approach at this juncture. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2:  The patient is a 45-year-old male with extensive acne and hidradenitis suppurativa.  He has taken numerous oral medications including corticosteroids, antibiotics and retinoids without benefit. The patient had some response to retinoids, but was unable to tolerate the side effect of hyperlipidemia. The patients provider recommended treatment with Enbrel and submitted a request for authorization. The Health Plan denied the request citing the experimental/investigational nature of the therapy in this clinical setting.The patient has extensive follicular disease that is poorly controlled with standard treatment modalities. Hidradenitis is a rare condition and there are no randomized, placebo controlled trials of medications for its treatment. Journal publications are generally limited to case reports for uncommon conditions such as this one. Enbrel, although not FDA approved for the treatment of hidradenitis suppurativa, has been shown to be effective in several case reports.  Because of the rarity of the diagnosis, there are no medications approved specifically for the treatment of hidradenitis suppurativa. Any treatment, including the medication that have been tried and failed, will likely be an off-label application of the drug. A trial of Enbrel as proposed by the patients provider is quite reasonable and medically appropriate.Based upon the information set forth above, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 45-year-old-male who suffers from cystic acne and hidradenitis suppurativa of the face neck, trunk and axillae.  Treatment with Accutane resulted in improvement of his skin condition, however it produced severe hyperlipidemia.  Prior treatment with various oral antibiotics was not effective. The patient has recently been treated with Rocephin, prednisone and dicloxicillin without benefit. His dermatologist has proposed a trial of Enbrel therapy. The Health Plan denied authorization for the treatment based on a determination that the proposed therapy is experimental/ investigational.At this stage in the patients treatment, all of the conventional modalities for the treatment of his hidradenitis suppurativa have been exhausted with disappointing results. There is simply no reasonable option other than TNF inhibitors such as Enbrel, that may afford the patient some relief from his symptoms. The medically monitored use of Enbrel has support in the literature and is a well reasoned approach. Accordingly, I conclude that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.