Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Psoriasis, arthritis
Treatment: Cosentyx
The insurer denied the Cosentyx.
The determination is upheld.

The patient has psoriasis and psoriatic arthritis. He has failed hydrocortisone, Taclonex, Elidel and betamethasone ointment. He has joint pain in his fingers and neck. At issue is the medical necessity of Cosentyx.

The requested health treatment of Cosentyx is not medically necessary for this patient. The required prescription drug(s) (those on formulary) are not contraindicated or likely to cause an adverse reaction by or physical or mental harm to the insured. The required prescription drugs(s) (those on formulary) are not expected to be ineffective based on the known clinical history and conditions of the patient and the patient's prescription drug regimen. The patient has not tried the required prescription drug(s) (those on formulary) while under their current or previous plan or another prescription drug(s) in the same pharmacologic class or with the same mechanism of action and such prescription drug(s) were discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event. The patient has not been stable for a long time on a prescription drug(s) selected by their health care provider for the medical condition under consideration. The required prescription drug(s) (those on formulary) are in the best interest of the patient because they will not likely cause a significant barrier to the patient's adherence to or compliance with the patient's plan of care, will not likely worsen a condition of the patient, or will not likely decrease the patient's ability to achieve or maintain reasonable functional ability in performing daily activities.
According to the American Academy of Dermatology Psoriasis Guidelines and medical literature, the preferred medicines Humira and Stelara are effective treatments for the management of psoriasis and psoriatic arthritis (1, 2). Within the peer-reviewed literature, according to Burness et al., "well-designed randomized clinical trials demonstrated that adalimumab 40 milligrams (mg) every other week (eow) effectively reduced the signs and symptoms of psoriasis and improved dermatology-specific and general measures of health-related quality of life, with these benefits sustained during long-term treatment" (3). Mease et al writes "Adalimumab significantly improved joint and skin manifestations, inhibited structural changes on radiographs, lessened disability due to joint damage, and improved quality of life in patients with moderately to severely active psoriatic arthritis (PsA)" (4). Langley et al. writes, "Treatment with ustekinumab for up to 5 years was safe and effective" (5). Kavanaugh et al concludes "In this post-hoc analysis of PsA patients with baseline peripheral arthritis and physician-reported spondylitis, ustekinumab-treated patients demonstrated significant improvements in axial signs and symptoms through week 24" (6).
The preferred agents are appropriate agents for the treatment of the patient's psoriasis and psoriatic arthritis. The formulary medications should be tried and failed prior to initiating Cosentyx.
It is noted that the patient has failed numerous therapies. However, there is no documentation provided that would justify the patient requiring treatment with Cosentyx prior to the formulary alternatives such as Humira or Stelara. There is no proof or documentation provided the patient has tried these preferred drugs and had an adverse effect or proof that the formulary tried drugs did not work for the patient.