Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis with Coexistent Plaque Psoriasis
Treatment: Otezla 30mg (milligrams)
The insurer denied the Otezla 30mg.
The denial is overturned.

The patient is an adult male with psoriasis and psoriatic arthritis for 12 years. He failed treatment with Enbrel, Remicade, Simponi, Cosentyx, Stelara, Xeljanz, Tremfya and Otezla (monotherapy for 3-4 months). At his recent office visit, he was treated with Humira 40 milligrams every other week, methotrexate 20 milligrams weekly and Celebrex 200 milligrams twice daily, and presented with residual active joint disease.  His liver function tests were elevated, and methotrexate was decreased to 15 milligrams weekly. He is also taking doxycycline for a chronic lumbar spinal infection following fusion surgery. The attending physician wishes to add Otezla to his current regimen of Humira and methotrexate, since it is not additionally immunosuppressive. Otezla was denied for this patient because it is being prescribed in combination with the biologic Humira. Skyrizi and Cimzia were recommended as plan-preferred alternatives. Appeal is for Otezla in combination with Humira and methotrexate for the treatment of refractory psoriasis and psoriatic arthritis.

The proposed treatment with Otezla in combination with Humira and methotrexate for the treatment of refractory psoriasis and psoriatic arthritis in this patient is medically necessary.

This patient with refractory psoriasis and psoriatic arthritis failed treatment with numerous biologics and DMARDs (disease-modifying antirheumatic drugs) as enumerated above. He is partially responsive to Humira 40 milligrams every other week, in combination with methotrexate 20 milligrams weekly and Celebrex. Methotrexate dosing was reduced to 15 milligrams weekly due to elevated liver function tests. This patient is also being treated with doxycycline for a chronic lumbar spinal infection following fusion surgery. The attending physician wishes to add Otezla to his current regimen of Humira and methotrexate, since it is not additionally immunosuppressive. As indicated by the attending physician, multiple published retrospective series (cited below) suggest that Otezla is safe and effective when used in combination with biologic therapies for patients with refractory psoriasis and psoriatic arthritis, such as this patient. The Plan alternatively suggests a trial of Cimzia or Skyrizi.  This patient already failed multiple other TNF (tumor necrosis factor) inhibitors, so the TNF (tumor necrosis factor) inhibitor Cimzia is unlikely to be helpful.  This patient also failed the IL-23 (Interleukin 23) inhibitor Tremfya, so the IL-23 (Interleukin 23) inhibitor Skyrizi is unlikely to be helpful. Both of these Plan-preferred alternatives are immunosuppressive, and switching this patient's Humira to either of these agents would risk worsening flare of his disease, along with immunosuppression in the setting of his chronic lumbar spinal infection. Thus, in this specific case, it is clinically appropriate and in accordance with standard of care in the rheumatology community to add Otezla to his current regimen of Humira and methotrexate. This could augment clinical response without adding further immunosuppression. Therefore, the proposed treatment with Otezla in combination with Humira and methotrexate for the treatment of refractory psoriasis and psoriatic arthritis in this patient is medically necessary.