Diagnosis: Dermatology.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Xeljanz.
The health plan's determination is upheld.

The patient is a female with alopecia (capitis) totalis. She has failed intralesional Kenalog and oral prednisone. She is very depressed due to the hair loss. The subject under review is the medical necessity for the requested medication Xeljanz 10 milligrams (MG).

The health plan's determination is upheld in whole.

The requested treatment of Xeljanz 10MG is not medically necessary for this patient's alopecia totalis. There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Xeljanz for this patient's condition as an accepted standard of practice in the United States (U.S.) prior to the conventional alternatives. There is no documentation the patient has exhausted based on the standard of care, all topical options, and that it would therefore be medically necessary to start systemic treatment with Xeljanz, which would carry a higher side effect profile.
The evidence-based literature is consistent and in line with the health plan's determination.
There is no documentation provided that would justify the patient requiring treatment with Xeljanz prior to the conventional alternatives. Therefore, Xeljanz is not medically necessary for this patient.