202103-135742
2021
United Healthcare Ins. Co. of N.Y.
Indemnity
Immunologic Disorders
Pharmacy/ Prescription Drugs
Medical necessity
Upheld
Case Summary
Diagnosis: Immunologic Disorders/Arthritis
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug, Xeljanz. The health plan's determination is upheld.
The patient is a female with psoriatic arthritis (PsA). The issue in this case is that Xeljanz XR is being denied by the health plan, reason cited is that it is not medically necessary as she has not failed or had an intolerance to two of the preferred products, including Cimzia, Humira, Simponi, Stelara or Tremfya. The reason cited is 'severe needle phobia' stated in a letter from her physician. Prior treatment: nonsteroidal anti-inflammatory drugs (NSAIDs) , Rheumate, Tizanidine, Prednisone and MTX.
At issue is the medical necessity of the requested prescription medication, Xeljanz.
I uphold, in whole, the health plan's determination of medical necessity.
No, the requested health service/treatment of Xeljanz XR is not medically necessary for this patient. She does not have a contraindication to one of the preferred agents, Cimzia, Humira, Simponi, Stelara or Tremfya. These medications are all indicated for psoriatic arthritis and are consistent with the standard of care. They are not inferior to the non-formulary drug, Xeljanz XR. Needle phobia is not a contraindication or intolerance to the preferred drugs covered by the health plan, including Cimzia, Humira, Simponi, Stelara or Tremfya. As stated, the patient does not have a contraindication to one of the preferred agents. A study published in Expert Review in Clinical Immunology concluded that 'CZP (Cimzia) demonstrated positive results in several domains of psoriatic disease, also in patients previously exposed to other tumor necrosis factor (TNF-a) inhibitors and in patients receiving re-treatment after treatment interruption'.