Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque psoriasis. 

Treatment: Otezla (apremilast) for the treatment of Psoriasis. 

The insurer denied coverage for Otezla (apremilast) for the treatment of Psoriasis. 

The denial is upheld. 

This is a female patient with a history of anxiety, depression, gallbladder removal, partial nephrectomy, and oophorectomy. The patient has plaque psoriasis. She has failed topical steroids. The request is for Otezla (apremilast). The use of phototherapy or use of disease-modifying antirheumatic drugs (DMARDs), such as methotrexate or cyclosporine is part of the first line of therapies after failure of creams/ ointments. 

According to the 2018 American College of Rheumatology and National Psoriasis Foundation guidelines, Phototherapy and oral agents for psoriasis (i.e., cyclosporine, and methotrexate) may be used first-line in various clinical situations. Cyclosporine may be effective long-term, but is normally reserved for intermittent use (up to 12 weeks) to control a flare so the patient can transition to another drug for long-term maintenance.  When used intermittently, a course of cyclosporine can induce an average decrease of greater than 75% in psoriasis severity. Methotrexate is considered a first-line systemic agent for plaque psoriasis that may be used continuously for many years or decades with durable benefits. 

Per Racz et al (2015), "Phototherapy is a first-line option for the treatment of moderate to severe psoriasis. Systematic reviews indicate near comparable efficacy of the different forms of phototherapy. Localized phototherapy can be an adjunctive treatment of recalcitrant plaques during systemic treatment of psoriasis." 

Per authors Greb et al. (2016), "methotrexate is an anti-inflammatory agent used to treat psoriasis, psoriatic arthritis, and other immune mediated disorders. The folic acid analogue methotrexate is used as an anti-neoplastic agent and treatment for inflammatory disorders including psoriasis, dermatomyositis, lupus erythematous, sarcoidosis, and systemic sclerosis. Despite the introduction of newer biologic agents, methotrexate remains a first-line systemic therapy for many patients with disorders of chronic inflammation." 

Methotrexate has proven efficacy, per West et al (2016), "many psoriasis patients requiring systemic therapy are likely to benefit to methotrexate ...as flexible dose adjustment and adaptation of route of dosing are applied under real-world conditions which would be expected to increase efficacy and reduce limiting adverse events." 

The patient is of childbearing potential and therefore acitretin is not a suitable choice.  However, the patient does not have elevated liver function tests (LFTs), liver disease, uncontrolled hypertension, or a history of skin cancer. The patient is not known to be actively family planning. The patient has no document to support contraindication, intolerance, or failure to phototherapy, methotrexate, or cyclosporine. 

Otezla (apremilast) was appropriately denied as the patient has no documented contraindications to phototherapy or systemic DMARDS such as methotrexate or cyclosporine. 
                                                 
The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for Otezla (apremilast) for the treatment of Psoriasis is upheld. The medical necessity is not substantiated.