Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication Otezla, 30mg tablets. The enrollee has psoriasis on her arms, hands, legs, and neck. The affected areas are red and mild in severity. She has tried Elidel and halobetasol, tacrolimus, hydrocortisone, 1%, and Locoid. The enrollees dermatologist noted the enrollee has joint pain; possibly psoriatic arthritis. Because of this condition, the provider believes phototherapy is not the most appropriate treatment option for this enrollee. The provider noted the enrollee has a diagnosis of hypertriglyceridemia, and because Cyclosporine and acitretin can cause an increase in serum triglycerides, these options would likely worsen the enrollees condition. The provider further noted treatment with injectable biologics like Humira, Enbrel, and Cosentyx can lower an individuals immune system and increase the risk of infections. This enrollee has psoriasis and psoriatic arthritis. Although the provider indicates concerns regarding treatment with injectable biologics, the medical literature indicates the medications Enbrel, Humira, and Cosentyx have been found to be safe and effective for psoriasis and psoriatic arthritis. In a retrospective chart review of 398 patients, Biologic agents used for the treatment of psoriasis resulted in adverse effects associated with withdrawal in four percent of the 545 administered treatments. This rate does not appear different from that of clinical trials. Approved medications for psoriasis include etanercept (Enbrel) and adalimumab (Humira), among others for psoriatic arthritis. Over the past decade, etanercept has proven to be effective as a single agent or when used in combination with other treatments. Although biologic agents have been associated with serious infections, demyelinating diseases, lymphomas, and leukemia, many of these associations occurred at rates similar to those observed in the general population, or the rates were so low that treatment benefit outweighed the risk. Etanercept remains an important and valuable option for the treatment of moderate to severe psoriasis and/or psoriatic arthritis. The medical literature also indicates tumor necrosis factor (TNF)-inhibitors, such as Enbrel and Humira are effective and tolerable for patients with moderate-to-severe plaque psoriasis. Adverse effects from the use of these medications are not common. Those at highest risk for adverse effects include the elderly and those with a history of malignancy, which do not pertain to this enrollee. The requested therapy with Otezla is not more effective than treatment with medications, such as Humira, Enbrel, and Cosentyx.                                                         Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.