Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Immunologic Disorders.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Xeljanz. 
The denial is upheld.

The patient is a female with alopecia areata. Her scalp has over 40% hair loss in patches. She has failed an intramuscular steroid injection. She has also failed finasteride-minoxidil topically. She has been on prednisone for Crohn's disease and Plaquenil for psoriatic arthritis. Xeljanz has been recommended by her provider.
At issue is whether the treatment Xeljanz is likely to be more beneficial than any standard treatment.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.

The proposed health service or treatment Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Xeljanz for this patient's condition as an accepted standard of practice in the U.S. prior to the conventional alternatives. There is no documentation the patient has exhausted all topical options, and that it would therefore be necessary to start systemic treatment with Xeljanz, which would carry a higher side effect profile.
For example, there is no documentation provided that the patient has tried and failed topical immunotherapy, such as Diphenylcyclopropenone (DPCP). Chiang et al writes in their 2015 study findings that for DPCP "treatment success, defined as 50% terminal hair regrowth, was reached in 71% of alopecia totalis patients and in 56% of alopecia universalis patients." (1) Moreover, there is no documentation that the patient has tried and failed topical squaric acid. Topical squaric acid dibutylester is a sensitizing agent which is also used for the treatment of alopecia areata and has been shown to be effective in several studies. (2) Moreover, according to the dermatology literature, the preferred medicines methotrexate and oral corticosteroids are effective treatments for the management of alopecia areata. (3-5) Within the peer-reviewed literature, Anuset et al 2016 writes "Methotrexate (MTX) combined with low- to moderate-dose oral corticosteroids (OC) may be an efficient and well-tolerated treatment for severe alopecia areata (AA)." Thus, methotrexate and corticosteroids are an effective first-line treatment for the management of severe alopecia. (4) Additionally, according to Phan et al "Methotrexate for alopecia areata: A systematic review and meta-analysis," published in the Journal of the American Academy of Dermatology 2019, "Methotrexate has reasonable effectiveness in patients with severe AA...Combination treatment results in a higher complete response rate than methotrexate stand-alone treatment...Methotrexate is an effective monotherapy or adjunct therapy in combination with corticosteroids in the treatment of severe AA." (5)
It is noted that the patient has tried and failed intramuscular steroids. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Xeljanz prior to the standard of care alternatives such as methotrexate in combination with oral corticosteroids, and the topical medications aforementioned.
Therefore, the proposed health service or treatment Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the patient.