Diagnosis Rheumatoid Arthritis
Treatment Acthar Gel The insurer denied Acthar Gel
The determination is upheld.

The patient has severe, advanced seropositive rheumatoid arthritis (RA). He has failed or had adverse effects to steroids (e.g. prednisone), Xeljanz, Actemra, SSz, methotrexate (MTX), Arava, intravenous immunoglobulin (IVIG), morphine, Sulfasalazine, (SSz), Dilaudid, Nucynta, oxycodone, oxymorphone and methadone. He is currently on prednisone 17.5 milligrams (mg) daily. The patient's provider is requesting Acthar gel. At issue is the medical necessity of the Acthar gel.

Acthar gel is not medically necessary; it is not the standard of care for the treatment of RA. Treatment of RA includes nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, disease modifying anti-rheumatic drugs (DMARDs) and biologics. He has tried several already but he has yet to try a tumor necrosis factor (TNF) antagonist (e.g. Humira or Enbrel) or a T cell inhibitor (e.g. Orencia or rituximab).