Diagnosis: Atopic Dematitis
Treatment: Dupixent
The insurer denied the Dupixent.
The determination is upheld.

This is a patient with severe atopic dermatitis (over 50% body surface area involvement). The patient has tried and failed topical therapies such as triamcinolone and fluocinonide. Eucrisa and Protopic were not seen in the patient's paid claim information, but burning and itching were reported for both topical Eucrisa and Protopic. At issue is the medical necessity of Dupixent.
The Dupixent is not medically necessary.
The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications such as methotrexate, or azathioprine. The patient is an appropriate candidate for methotrexate, or if gastrointestinal (GI) upset is an issue with methotrexate, she is also an appropriate candidate for cyclosporine. Oral medications used for moderate to severe atopic dermatitis, and/or phototherapy, are appropriate for this patient at this time. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature [2-5] and standards of care, the requested Dupixent is not medically necessary.
Modern dermatology literature [2-5] supports use of preferred medications as similarly efficacious to the requested Dupixent, particularly for a patient with a limited history of systemic atopic dermatitis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. For severe cases both second-like topical therapies and/or oral/systemic immunomodulators are also needed for concurrent use with Dupixent.
Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature. (2)