Diagnosis: Vitiligo
Treatment: Compounded tofacitinib cream

The insurer is denied coverage for compounded tofacitinib cream. The denial is overturned.

This is a male patient with a history of vitiligo. The patient had tried and had an inadequate response to light therapy, Excimer laser therapy and topical Protopic. Compounded tofacitinib 2/5 cream was discussed at the office visit.

As per Damsky & King (2017), "New molecularly targeted therapeutics are changing
dermatologic therapy. Janus kinase-signal transducer and activator of transcription (JAK-STAT) is an intracellular signaling pathway upon which many different proinflammatory signaling pathways converge. Numerous inflammatory dermatoses are driven by soluble inflammatory mediators, which rely on JAK-STAT signaling, and inhibition of this pathway using JAK inhibitors might be a useful therapeutic strategy for these diseases. Growing evidence suggests that JAK inhibitors are efficacious in atopic dermatitis, alopecia areata, psoriasis, and vitiligo." And as per Craiglow & King (2015), "Recent advances in the understanding of the pathogenesis of vitiligo suggest that Janus kinase inhibitors may be a therapeutic option" and this study suggested "that tofacitinib and other Janus kinase inhibitors may be effective in the treatment of vitiligo."

Based on the review of the medical record and literature, compounded tofacitinib cream is considered medically necessary for this patient. The patient has tried and failed conservative therapy. The patient would like to avoid immunosuppressive medication and systemic medication that could have an adverse effect. Topical tofacitinib has minimal absorption and much less potential for adverse consequences. Therefore, the request for tofacitinib topical should be approved.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for is substantiated. The insurer's denial should be overturned.