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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis and molluscum contagiosum. The provider noted that the patients eczema was unchanged since the last visit, with a current flare on the face and eyelids. The patient has been treated with phototherapy, tacrolimus, triamcinolone, ketoconazole shampoo, and fluocinolone. Physical examination findings included erythematous papules on the left chest, left abdomen, neck, and left arm.  Many erythematous scaly plaques were noted on the arms and legs. The patients parent has requested authorization and coverage for Dupixent 400 mg subcutaneously on day one and 200 mg every two weeks thereafter. The Health Plan denied the request and reported that the requested medication regimen is not medically necessary for the treatment of this patient. At issue in this case is whether Dupixent 400 mg subcutaneously on day one and 200 mg every two weeks thereafter is medically necessary for the treatment of the patients medical condition. Researchers reported, Dupilumab was first approved for adults in March 2017, and two years later in adolescents 12 years and older. Per the authors, Our multicenter retrospective review includes 111 patients who were treated for an average of nine months (and as long as 19 months). These data, collected before adolescent labeling, support positive treatment response and tolerability of long-term use of dupilumab in children as young as three years with moderate to severe atopic dermatitis (AD). The only U.S. Food and Drug Administration (FDA) approved treatment at this time for children is systemic steroids which have longterm risks of stunting growth and risks of altering the current immunization schedule for children. Researchers reported, Systemic immunomodulating medications are a prevalent treatment option for the management of chronic and/or severe inflammatory diseasesthese agents are indicated and recommended in AD care for the subset of adult and pediatric patients in whom optimized topical regimens and/or phototherapy do not adequately control the disease, or when quality of life is substantially impacted. Per the authors, the management of AD with systemic corticosteroids, while used frequently and shown to temporarily suppress disease, should generally be avoided because of short- and long-term adverse effects and an overall unfavorable risk-benefit profile. In this case, the patient has been treated with standard therapies, including systemic treatment with phototherapy, without significant benefit. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Dupixent 400 mg subcutaneously on day one and 200 mg every two weeks thereafter is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The 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 a similar medical condition.