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202110-142612

2021

Excellus

PPO

Immunologic Disorders

Pharmacy/ Prescription Drugs

Medical necessity

Upheld

Case Summary

Diagnosis: Psoriasis Vulgaris

Treatment: Skyrizi

The insurer denied coverage for Skyrizi.

The denial is upheld.

This adult patient has psoriasis vulgaris. The provided documentation does not indicate a contraindication to alternative Food and Drug Administration (FDA)-approved formulary medications, such as Humira which has been shown to be an effective first-line therapy for psoriasis and psoriatic arthritis.

There is no medical and scientific literature and/or evidence-based clinical practice guidelines that strongly support the administration of Skyrizi for this patient's condition above reasonable alternatives as an accepted standard of practice in the U.S (United States). According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, alternative effective treatments for the management of psoriasis are available and appropriate for this patient (1-3). Lanna et al (4) discuss the safety and efficacy of Humira in the treatment of psoriasis vulgaris.

As such, the health care plan acted reasonably in denying Skyrizi for this patient as numerous formulary options exist in the treatment of the patient's condition. The provided medical notes do not provide any evidence of an absolute contraindication for the use of available therapies or unique clinical situation which would specifically warrant Skyrizi.

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for Skyrizi is upheld. Medical necessity is not substantiated.

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