Diagnosis: Vitiligo

Treatment: tofacitinib compound

The insurer denied coverage for tofacitinib compound

The denial is overturned.

The patient has a diagnosis of vitiligo. The patient has failed therapy with elidel, topical steroid, betamethasone, as well excimer light therapy (XTRAC). The requested medication is topical compounded tofacitinib cream.

Based on the submitted documentation, topical tofacitinib cream is medically necessary for the treatment of the patient's condition. The patient has failed standard topical therapies, which would include topical steroids as well as non-steroidal option-elidel cream. Vitiligo is an autoimmune disease and requires appropriate therapy. The use of topical anti-inflammatory agents is within the standard of care prior to proceeding to systemic therapies with associated increased risks. The use of topical tofacitinib under the supervision of the dermatologist is medically necessary and the decision is overturned in whole.

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 Tofacitinib Compound is overturned. Medical Necessity is substantiated.