Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Otezla 30 milligram (mg) tablet
The insurer denied Otezla 30 milligram (mg) tablet.
The determination is upheld.


The patient has psoriasis. Body surface area affected is 20%. She has failed halobetasol and calcipotriene. The medication under review is Otezla 30 milligram (mg) tablet.

The requested health service/treatment of Otezla 30 mg tablet is not medically necessary for this patient.
The request for Otezla is not medically necessary because the submitted records do not indicate that member has failed or has a contraindication or had an inadequate response to either conventional systemic therapy or phototherapy. According to the "national physician specialty society recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines-and dermatology literature, phototherapy and methotrexate are effective treatments for the management of psoriasis (1, 2).
Within the peer-reviewed literature, Racz et al writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (3). Mehta et al writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with greater than (>) 10 % affected body surface area who have not responded to topical treatments...narrowband ultraviolet B (NB-UVB) ..effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile" (4).
Additionally, West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (5).
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not medically necessary. It is noted that the patient has failed numerous halobetasol and calcipotriene. However, there is no documentation provided that the patient has tried and/or failed phototherapy or methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options. It is noted that the provider states patient would not be a candidate for oral systemic therapy because she has Crohns disease. However, methotrexate is actually a treatment for Crohn's disease.  "Effectiveness and safety of methotrexate monotherapy in patients with Crohn's disease refractory to anti-tumor necrosis factor alpha (TNF-): results from the ENEIDA registry" states that "The benefits observed suggest methotrexate monotherapy could be a valid option in Crohn's disease patients." Therefore, methorexate is not contraindicated in Crohn's disease.
The administration of Otezla is not strongly supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature.