Diagnosis: Alopecia areata

Treatment: Xeljanz extended release (XR)

The insurer denied coverage for Xeljanz XR.

The denial is upheld.

This is a female patient with a past medical history of alopecia areata. The patient was seen at a Dermatology office visit for worsening alopecia areata. The Dermatologist is requesting coverage of Xeljanz extended release (XR) for the patient.

Xeljanz XR is not medically necessary for the patient's condition, alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, calcipotriene, and anthralin. (1-11) Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata, further studies are needed to demonstrate the long term efficacy and safety of Xeljanz and Xeljanz XR. It is noted that the Food and Drug Administration (FDA) released a statement in early 2019 finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10mg two times per day. (1)

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned non-systemic options for the treatment of alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possible improve alopecia areata, including light therapy, squaric acid, diphenylcyclopropenone (DPCP), and anthralin. (9-10) Based on the information provided, the health care plan acted reasonably in denying the coverage for Xeljanz XR.

The insurer's denial of coverage for Xeljanz XR is upheld. Medical necessity is not substantiated.