Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Atopic Dermatitis.
Treatment:  Dupixent.

The insurer denied coverage for Dupixent.  The denial is overturned.

This patient is a female with a history of atopic dermatitis.  An office visit states that the patient was following up for eczematous dermatitis.  The patient was seen a few weeks prior, at which time she was prescribed halobetasol propionate 0.05% topical.  The patient was taking methotrexate sodium 2.5 mg and folic acid.  The patient reported feeling better with medication, but her symptoms were interfering with her personal relationships.  The patient's physical exam showed skin type III and eczematous dermatitis.  The patient was noted to have erythematous eczematous patches refractory to current treatment. 

Treatment plan included methotrexate sodium 2.5 mg.  The patient was continued on folic acid and hydrocortisone topical ointment daily for no longer than two weeks with plan to follow up in two weeks.  An office visit noted inadequate control of this patient's atopic dermatitis.  The patient was advised to continue halobetasol twice a day 2 weeks on/off, loratadine every day and discontinue hydrocortisone ointment.  The patient was continued on methotrexate and folic acid.  It was noted that methotrexate was not working, and the patient had used this for over two months.  It was also noted that the use of tacrolimus ointment, Eucrisa ointment alongside several topical corticosteroids were not working either, and the patient needed Dupixent as an ideal treatment that can also treat her concomitant asthma.

According to Gooderham, et al. (2018), "...Dupilumab has recently been approved in the United States and Europe for the treatment of adult patients with moderate-to-severe [atopic dermatitis (AD)].  Clinical trials have shown that adults with moderate-to-severe AD who receive weekly or biweekly Dupilumab injections have significantly improved clinical and patient-reported outcomes, including Eczema Area Severity Index, SCORing Atopic Dermatitis, Dermatology Life Quality Index, and itch Numeric Rating Scale scores...Dupilumab, as monotherapy or with concomitant use of topical corticosteroids, can significantly improve clinical outcomes and quality of life in patients suffering from moderate-to-severe AD." 

As per Prezzano & Beck (2017), "Many patients with mild to moderate atopic dermatitis (AD) are managed by identifying and avoiding allergens and irritants, ensuring skin moisturization, and graded use of topical corticosteroids and/or calcineurin inhibitors.  Most systemic therapies are "off label" in the United States and include phototherapy, cyclosporine, mycophenolic acid precursors, azathioprine, and methotrexate.... "
              
Based on the review of the medical record and literature, the patient has a history of atopic dermatitis and asthma that has been refractory to treatment.  The patient has a body surface area of 10% and an IGA score of 3.  The patient has tried and failed methotrexate 2.5mg, halobetasol propionate 0.05% topical ointment, tacrolimus ointment, Eucrisa ointment, folic acid, and loratadine.  In this case, the patient has tried and failed potent conservative treatment.  Literature supports the effectiveness and use of Dupixent (dupilumab) for the treatment of atopic dermatitis.  Therefore, the request for Dupixent is considered medically necessary for this patient, who has a relatively refractory atopic dermatitis.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for Dupixent (dupilumab) SC injection should be overturned.  The medical necessity is substantiated.