Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with moderate to severe atopic dermatitis (more than 30% body surface area involvement) that includes the chest, abdomen, back, forehead, and upper arms. The patient has tried and failed topical Triamcinolone, Mometasone, and Hydrocortisone, as well as oral Prednisone. 

The health plan's determination is upheld, in whole. 

The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications such as Methotrexate, Azathioprine, or Mycophenolate Mofetil. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, as per the modern dermatology literature [2-4] and standards of care, the requested Dupixent is not medically necessary. 
 It should be emphasized that atopic dermatitis is an ongoing inflammatory disease affecting the skin, with the need to control any immune/inflammatory hypersensitivity being for some patients intermittent, and for some patients to be controlled on a chronic and ongoing basis. 
The usual treatment is with topical steroids and topical immunomodulators [1-4], emolliation, mild soap, avoidance of irritants, and similar conservative treatments. Weather changes, physical illness, and even emotional stress can trigger atopic dermatitis. Topical steroids, as well as topical nonsteroidal agents such as Elidel, tacrolimus, and Eucrisa are the mainstay of therapy for this condition. The patient has not failed all reasonable topical therapies, in that topical calcineurin inhibitors and Eucrisa have not all been tried and failed. 
Furthermore, systemic therapies are often needed in conjunction with topical therapies for more severe and/or treatment-resistant cases of atopic dermatitis [1-4], and such appears to be the case with this patient. 
Dupixent is only truly medically necessary when other similar, reasonable, and standard treatments have been tried and failed, but such is not the case at this time. If topical therapies cannot control this patient's atopic dermatitis, then systemic therapies become standard of care in order to achieve proper disease control, physical functioning and quality of life, and neither of these options have been exhausted to control this patient's chronic condition. 
Modern dermatology literature reviews [2-4] and American Academy of Dermatology Clinical Guidelines in the treatment of atopic dermatitis [1] support use of phototherapy, Methotrexate, Azathioprine, or Mycophenolate Mofetil, and/or brief courses of systemic corticosteroids as potential and appropriate systemic therapies for more severe cases of atopic dermatitis. These treatments are both time-tested, standard of care, and supported by modern dermatology literature and larger studies/comparative trials.
While Dupixent is a relatively new agent in the systemic treatment of atopic dermatitis, it is not confirmed to be significantly superior to all the aforementioned alternative, more cost-effective and time-tested oral and light therapies described above. To date, this patient has had no history of systemic therapies. 
Accordingly, while systemic therapy is indicated for this patient, and Dupixent is one form of systemic therapy, Dupixent is being prescribed out of preference/convenience and not true medical necessity because other, more studied and cost-effective, alternatives have not yet been tried to date. The request for Dupixent is therefore not medically necessary, and the health plan acted with sound judgement and in the best interest of this patient's particular clinical scenario by denying coverage of Dupixent.