Diagnosis: Skin Disorders
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug.
The health plan's determination is upheld.

The patient is a female with moderate to severe psoriasis (15% body surface area involvement) of the scalp, hands, and lower extremities. The patient has tried and failed topical Mometasone, Fluticasone, and Salicylic Acid, as well as intralesional Kenalog and oral Otezla.

A request for Skyrizi is under review for medical necessity.

The health plan's determination of the medical necessity of Skyrizi is upheld.

No. Because first line and standard treatments such as Methotrexate have not been tried to date, and despite Methotrexate being medically appropriate for this patient with proper monitoring and counseling, Skyrizi is being prescribed not out of medical necessity but out of patient and/or provider convenience or preference. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as Methotrexate.

Modern dermatology literature [1-4] supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Skyrizi, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend the use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Skyrizi is not medically necessary.