Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis

Treatment: Dupixent 300 milligrams/2 milliliters SC SOSY

The insurer is denied coverage for Dupixent 300 milligrams/2 milliliters SC SOSY.

The denial is upheld. 

This was a female with a history of asthma and atopic dermatitis (eczema). The patient was seen for a follow up visit. The patient's physical examination revealed multiple erythematous lesions located on her bilateral lower legs and bilateral hands with greater than 10% body surface area involved. The patient's overall condition was described as moderate, and status was described as unchanging. The patient had failed topical Triamcinolone, Halobetasol, Betamethasone, Westcort, Elidel, Protopic, Tacrolimus, Eucrisa, and oral Prednisone. Dupixent injection was recommended.   

The office visit note stated that the patient's condition was not improving despite treatment. The patient's skin showed multiple erythematous patchy lesions on bilateral lower legs, bilateral hands, and face. The patient's overall condition was documented as moderate to severe. The note stated that the patient was not a good candidate for Methotrexate and Cyclosporine due to the side effects involved and the child bearing years of this patient. It was also noted that the patient was not a good candidate for light therapy due to her school schedule which didn't allow her to be compliant with recommended treatment sessions.  

According to Spergel, J.M. (2020), "the proper sequence of therapy for severe atopic dermatitis would be topical emollients, topical corticosteroids, wet wraps, phototherapy, cyclosporine, and methotrexate." As per Shah, et al. (2018), "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk." And, according to Howell, Ghamrawi, Strowd & Feldman (2020), "Cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil are systemic agents available for the treatment of refractory [atopic dermatitis]; however, insufficient data exist to indicate the superiority of any one agent. Dupilumab is a safe and efficacious injectable therapy in elderly patients."                                                         

Based on the review of the medical record and the literature, Dupixent is not considered medically necessary for this patient. This patient had a history of asthma and atopic dermatitis. Though the patient had tried and failed Betamethasone, Halobetasol, Triamcinolone, Prednisone, Tacrolimus Elidel, and Eucrisa, the patient had not tried other safe and effective alternatives, such as methotrexate. Current peer-reviewed literature supports the use of phototherapy, cyclosporine, and methotrexate for this patient's diagnosis of atopic dermatitis and age. The medical records do not indicate that this patient was currently pregnant or nursing, or had a history of systemic malignancy, elevated liver function tests, or recurrent infections that would make this patient a poor candidate for methotrexate use. Therefore, Dupixent 300 milligrams/2 milliliters SC SOSY 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.

Based on the above, the medical necessity for Dupixent 300 milligrams/2 milliliters SC SOSY is not substantiated.  The insurer's denial should be upheld.