Diagnosis: Psoriasis
Treatment: Skyrizi
The insurer denied the Skyrizi.
The determination is upheld.

The patient has moderate to severe psoriasis of the scalp, trunk, and extremities. The patient has tried and failed topical triamcinolone, clobetasol, and ketoconazole shampoo, as well as oral Otezla (no improvement for over a year, and with severe gastrointestinal (GI) side effects). At issue is the medical necessity of Skyrizi.

The Skyrizi is not medically necessary. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either methotrexate or cyclosporine. These medications are as appropriate for a patient with a history of only topical therapy, as is the requested Skyrizi. Both methotrexate and cyclosporine can be monitored for patients with fatty liver and elevated cholesterol. Cholesterol elevation can be treated with statins to both allow for treatment response and to improve the likelihood of clinical improvement for any systemic therapy.

Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Skyrizi, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommends 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.