Diagnosis:Immunologic disorders
Treatment: Prescription drugs

Diagnosis: Immunologic disorders/other/Psoriatic arthritis
Treatment: pharmacy/ Prescription drugs/Otezla
The plan denied the service as not medically necessary. The health plan's determination is overturned in whole.

This is a patient with psoriatic arthritis. The patient has a past medical history (PMH) of asthma/chronic obstructive pulmonary disease (COPD), which is why methotrexate (MTX) has not been tried. Cyclosporine is not effective in psoriatic arthritis (PsA).
The requested health service/treatment of Otezla is medically necessary for this patient. The patient has a PMH of asthma/COPD. MTX is not appropriate due to the patient's PMH of asthma/COPD and cyclosporine is not effective in PsA. Per UpToDate, potential respiratory complications of MTX include 'interstitial pneumonitis (rheumatoid arthritis 1%), chronic obstructive pulmonary disease, cough, epistaxis, pharyngitis, pneumonia (including Pneumocystis jirovecii), pulmonary alveolitis, pulmonary disease, pulmonary fibrosis, respiratory failure, upper respiratory tract infection'. Thus, it would not be appropriate to try MTX in a patient with underlying lung disease.