Diagnosis: Rheumatoid Arthritis and Atopic Dermatitis

Treatment: Rinvoq 15 milligrams (mg)

The insurer is denied coverage for Rinvoq 15 milligrams (mg).

The denial is overturned.

This case involves a female who has a history of undifferentiated connective tissue disease manifesting with seronegative rheumatoid arthritis as well as patchy alopecia and sicca disease. The documentation indicated she has been previously treated with methotrexate and Enbrel. She has also been treated with Dupixent for atopic dermatitis; however, she discontinued use given the ineffectiveness. She did report pain as well as swelling and stiffness to her hands, back, and neck which have worsened since therapy was discontinued. The physician indicated she also has increasing elevations in inflammatory markers. A biologic is required for treatment of her condition given the severity of disease and prior robust response to biologic therapy. The documentation indicated there was also no evidence that the recommended medication Kevzara would be effective in treating atopic dermatitis which is why the requested Rinvoq is a better option.

Based on the medical records available the patient has inflammatory arthritis manifested by seronegative rheumatoid arthritis and atopic dermatitis, the requested Rinvoq is appropriate because there is good pre-liminary data indicating that Rinvoq will address both conditions.

The reviewer is aware that the Food and Drug Administration (FDA) has not approved Rinvoq for atopic dermatitis. However, preliminary evidence is very promising and as such that would appear appropriate to offer this medication to this patient. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Rinvoq 15 milligrams (mg) for the treatment of rheumatoid arthritis and atopic dermatitis is overturned. Medical Necessity is substantiated.