Diagnosis: alopecia areata

Treatment: Xeljanz XR

The insurer is denied coverage for Xeljanz XR

The denial is overturned.

This female patient has a history of seborrheic dermatitis of the scalp and with alopecia areata that affects 50% of her scalp and facial hair.

The patient is currently stable with her current regimen. It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following successful therapy having failed numerous topical and oral alternatives. As a result, the denial is reversed and the use of xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment.

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 Xeljanz XR is overturned. The medical necessity is substantiated.