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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis (AD). The patient reported a body and facial rash. She has been treated with doxycycline, topical steroids, including hydrocortisone and triamcinolone, and a calcineurin inhibitor Elidel. The provider noted that the patient has a long-standing history of a facial rash.  In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted that the patient has failed treatment with hydrocortisone, vitamin E, and Aquaphor. Physical examination findings included a well demarcated scaly plaque on the dorsal hand and scaly patches around the eyes. A biopsy was performed and revealed vesicular spongiotic dermatitis. The differential diagnosis was noted to be either allergic contact dermatitis, atopic dermatitis, or other spongiotic diseases. In the Independent Medical Review Application/Complaint form, the patient reported she is embarrassed to go out in public and AD affects her social life. She also reported she has been patch tested twice, both with negative results. Review of the submitted photographs showed moderate inflammation and redness. The patients parent has requested authorization and coverage for Dupixent injections. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Dupixent injections are medically necessary for the treatment of the patients medical condition. Scientists reported, Dupilumab was U.S. Food and Drug Administration (FDA) approved for adults (aged 18 years and older) and adolescents (aged 12-17 years) in March 2017 and March 2019, respectively, for the treatment of moderate-to-severe AD that has not adequately responded to topical prescription therapies, or when such therapies are not advisable. The authors also noted, Efficacy and safety of dupilumab in the treatment of AD has been demonstrated in numerous clinical trials. Researchers reported, Depression, anxiety, and suicidal ideation should be considered by doctors when treating patients with AD. Because AD disease improvement appears to reduce these risks, this should be a priority. In this case, the patient has moderate to severe AD as shown in the submitted photographs. The patient has been treated with medications, including doxycycline, hydrocortisone, triamcinolone, and Elidel. The patient reported that she is embarrassed to go out in public and AD affects her social life. Dupixent is safe and effective for the treatment of AD and is FDA approved for the treatment of adolescent patients. The medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent injections are 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.