The patient has seronegative rheumatoid arthritis (RA). Other past medical history (PMH) is degenerative joint disease (DJD), depression, hypothyroidism and asthma. The patient is feeling 'okay' on Humira (getting samples) per her provider's note. Prior treatment: Plaquenil (not tolerated due to vomiting), arava (migraine's) and Enbrel. The patient has allergies to nonsteroidal anti-inflammatory drugs (NSAIDs) and sulfa drugs.
The issue in this case is that the use of Humira is being denied by the health plan, as the patient has not tried either MTX (methotrexate), leflunomide, sulfasalazine, or hydroxychloroquine.

The health plan's determination is upheld. Humira is not medically necessary for this patient. It's reasonable for the patient to try MTX with close monitoring of LFT's. MTX is not contraindicated given the patient has normal LFT's when checked recently. MTX is not expected to be ineffective based on the known clinical history and conditions of the patient and the patient's prescription drug regimen.