Diagnosis: Plaque psoriasis.
Treatment: Taltz.

The insurer denied coverage for Taltz.

The denial is upheld.

This is a female patient with plaque psoriasis affecting 10% body surface area (BSA). The patient has failed Cosentyx, topical steroids, and phototherapy. She has a history of fatty liver, diabetes, and morbid obesity. The patient has a family history of malignancy. Her maternal grandfather had prostate cancer and her mother had breast cancer. The patient's dermatologist requested the medication Taltz for psoriasis.

As per Menter et al. (2019), the use of tumor necrosis factor (TNF) inhibitors has relative contraindications for patients with the following: untreated hepatitis B infection; history of lymphoreticular malignancy; active infection (including tuberculosis) or sepsis; New York class III or IV congestive heart failure (CHF) or pre-existing multiple sclerosis. Absolute contraindication would be a history of allergic reaction to a therapeutic agent or vehicle. Garcia-Doval et al. (2016)'s study found that "[in] current clinical practice, treatment with anti-TNF drugs was not associated with a higher risk of serious infections than treatment with nonbiologic systemic therapy." As per Bartos et al. (2016), "Biologics are highly effective treatments for moderate-severe psoriasis with a high percentage of patients achieving 75% improvement in Psoriasis Area Severity Index (PASI75) at 12 weeks."

Based on the review of the medical record, this is a patient with plaque psoriasis affecting 10% of BSA. The patient has a history of fatty liver and a family history of malignancy. However, the patient does not have a demyelinating disorder, CHF, lupus like syndrome or active infection. She is not immunosuppressed or immunocompromised. The patient does not have any personal history of malignancy. There is no documented relative or absolute medical contraindication to the use of the insurer's preferred medications. The patient has no documented trial and failure with any of the Food Drug Administration (FDA) approved options of Enbrel, Cimzia, infliximab, Inflectra, or Avsola. There is no exception for Taltz. Thus, the medication Taltz is not considered medically necessary for this patient at this time.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of the medication Taltz for psoriasis should be upheld. The medical necessity is not substantiated.