Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pre-approve tertiary dermatology care and treatment with Xeljanz.
You asked the Plan to pre-approve this service. You say that you prefer to see the requested provider for this
treatment. The Plan denied this request. The QIC overturned the Plans denial. The Plan requested a reopen and
stated that the QIC did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is
coverage for continued care by a tertiary level provider. The QICPhysician Reviewer
determined that the enrollee was receiving off-label treatment with a JAK inhibitor for alopecia areata and that
such care at a tertiary level academic institution was reasonable and necessary. The Plan requested a reopen and
stated that the "Alopecia areata is not listed in any compendia to treat with Xeljanz". Therefore, it is not
covered by Medicare as a medically accepted use and should not have been approved for that reason." The plan
also notes that the drug is being provided as samples by the treating physician. In addition, the Plan notes that
the request was not for follow-up of alopecia areata, but rather for the treatment of precancerous skin lesions,
as indicated by the codes requested. Finally, the Plan notes that alopecia areata is a cosmetic condition, and that
there is a black box warning regarding immunosuppression for the use of the requested drug.
Our Medical Directors says that the medical records show you have a listed diagnoses of Alopecia areata,
unspecified, and Other long term (current) drug therapy. The requested procedure codes included a
comprehensive office visit for an established patient, destruction of a benign skin lesion, destruction of 2 to 14
benign or premalignant lesions, and tangential biopsy of a single skin lesion. The records show on February 18,
2020 it is documented that you were doing well on oral tofacitinib for about 16 months. It is noted that samples
were provided. The appeal records show you argued that the provider is more convenient to your residence and that
he had received services from the requested provider before. Our Medical Director states the Plan is correct in
this case. The documentation does not support that your medical condition is such that care from a tertiary
level academic institution is medically reasonable and necessary for the management of the condition. There is
no documentation to show that you could not be safely transitioned to an in-network provider. Finally, Xeljanz
(Tofacitinib) is not FDA-approved for the treatment of alopecia areata. While there is no single reliably
effective therapy for alopecia areata, there are data in the medical literature supporting the use of Xeljanz
(Tofacitinib) for treatment of this disorder. We looked at this physician's review, the file, and Medicare rules.
Based on this information, we decided that Medicare rules for coverage of this service have not been met.
Therefore, we decided that the Plan does not have to pre-approve a tertiary level of care at the requested provider.