Diagnosis: Ulcerative Pancolitis.

Treatment: Xeljanz 10mg.

The insurer is denied coverage for Xeljanz 10mg.

The denial is overturned.

This female patient has a history of ulcerative pancolitis.

Xeljanz is Food and Drug Administration (FDA) approved for the treatment of adult patients with moderately to severely active ulcerative colitis (UC). The patient is being prescribed Xeljanz for a diagnosis of ulcerative pancolitis. It was noted the patient was previously treated with Apriso, Valcyte, Entyvio, and infliximab. It was noted the patient was not advised to switch to Humira as she had failed Remicade as evidenced by adequate doses and levels with no antibodies. The American Gastroenterological Association (AGA) recommends "In adult outpatients with moderate-severe ulcerative colitis who have previously been exposed to infliximab, particularly those with primary non-response, the AGA suggests using ustekinumab or tofacitinib, rather than vedolizumab or adalimumab for induction of remission." The patient started Xeljanz. Continuation of Xeljanz 10mg twice daily is medically necessary given the failure of other alternatives and duration of use.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the Xeljanz 10mg is overturned. The medical necessity is substantiated.