Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with psoriasis. Previously, the patient reported a rash on her arms, back, genital area, and scalp which had been present for three months. The provider noted psoriasiform plaques were present over the patients scalp, lower back, right thumb, and bilateral elbows. Otezla samples were provided to the patient. Later, the provider noted psoriasiform plaques on the patients scalp, low back, right thumb, and bilateral elbows had improved by 30% while taking Otezla. The provider noted that the patient is not a candidate for treatment with disease-modifying antirheumatic drugs (DMARDS) or phototherapy. The patient had failed treatment with betamethasone, mometasone, and Eucrisa. The provider also noted the patient showed improvement with no adverse effects after eight weeks of treatment with Otezla. The patient has requested authorization and coverage for Otezla 30 mg tablets. 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 Otezla 30 mg tablets are medically necessary for treatment of the patients medical condition. Studies reported that psoriasis is a chronic common immune-mediated disease with frequent remitting/relapsing courses, has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The authors noted that at least one third of diagnosed patients have moderate or severe psoriasis and require continuous treatment to control disease activity. Studies reported that apremilast is a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Per the authors, its effects on cyclic adenosine monophosphate-regulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. Researchers also noted ESTEEM 1 study confirmed the efficacy of apremilast in psoriasis. Per Papp and colleagues, in the ESTEEM 1 study, apremilast demonstrated significant improvements in the mean percentage change in the psoriasis area and severity index (PASI) score and in pruritus. PASI response was maintained over 52 weeks with continued apremilast treatment. In this case, the patient is not a candidate for treatment with disease-modifying antirheumatic drugs (DMARDS) or phototherapy. The patient had also failed treatment with betamethasone, mometasone, and Eucrisa. The patients provider reported she showed improvement with no adverse effects after eight weeks of treatment with Otezla. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla 30 mg tablets 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.