Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 46-year-old male with a history of chronic plaque type psoriasis who has recurrent psoriatic skin disease. He has tried standard therapies including topical Dovonex, topical retinoids and topical and intralesional corticosteroids with chronic exacerbations and incomplete clearance. The patient has requested authorization and coverage for excimer laser treatments. The Health Plan has denied coverage for the requested therapy on the basis it is considered investigational for treatment of the patients condition.Traditionally, psoriasis has been difficult to treat successfully. Some patients respond better to certain therapies than other patients. At present, there is no method to determine which therapy will be most effective for a particular patient. Therefore, most providers will usually consider risk/benefit ratios and prescribe treatment accordingly.This patient has tried low risk treatments that have not been completely effective in treating his moderate psoriasis. The excimer laser system, which delivers narrow band high dose LEVB, has been shown in numerous studies to be highly effective with a low risk to the patient. The FDA approved excimer laser treatment in 2000. In 2003, a consensus statement on the treatment of psoriasis concluded targeted phototherapy was an appropriate option for treatment of moderate disease. Furthermore, excimer laser therapy has been shown to be equally or more effective and safer than traditional ultraviolet B therapy.Based upon the information set forth above, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: This patient is a 46-year-old male with plaque psoriasis, which involves his extremities and covers over 10% of his body. The patient has failed ultrapotent topical steroids and topical retinoids. The next line of treatments, with the exception of targeted laser, involves systemic or widespread toxicity. The patient wishes to receive excimer laser treatments. The Health Plan states peer-reviewed studies has not shown laser therapy is more efficacious in the treatment of psoriasis than standard therapies.The patient has failed topical agents necessitating more aggressive treatment options. Though studies of laser therapy for psoriasis are limited, preliminary data demonstrates excimer laser treatment is more efficient as it avoids exposing healthy skin to harmful effects. There is sufficient evidence of the efficacy and safety of excimer laser to warrant its use in this clinical setting. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 46-year-old man with progressively worsening psoriasis of his extremities, covering approximately 10% of his body surface. Treatment has included topical retinoids, Dovonex, and topical corticosteroid injections, all without success. Because of these treatment failures, his dermatologist recommends the patient receive localized excimer laser treatments. The Health Plan has denied coverage for excimer laser therapy indicating it is an investigational treatment for psoriasis.The excimer laser was approved in 2000 by the FDA for use in the treatment of vitiligo and psoriasis. It has also been deemed an appropriate and effective treatment by the American Academy of Dermatology, the American Medical Association, and the National Psoriasis Foundation. There is a voluminous amount of medical literature supporting the efficacy of excimer laser therapy for patients with psoriasis when other treatment modalities fail. Excimer laser therapy is a standard second-line treatment for patients such as this one. Accordingly, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.