Diagnosis: Psoriasis
Treatment: Cosentyx sensoready pen
The insurer denied Cosentyx sensoready pen
The determination is upheld.

The patient has moderate to severe psoriasis of the scalp, neck, and labia. The patient has a history of chronic canker sores, so Methotrexate has been avoided. For safety concerns by the parents and dermatologist, cyclosporine has been avoided. Topical triamcinolone, betamethasone, and mometasone have been tried and failed.
At issue is the medical necessity of Cosentyx.

The requested Cosentyx is not medically necessary.
Although phototherapy is acceptable for use for many psoriasis patients, the location of this patient's psoriasis (such as the scalp and labia) precludes phototherapy from being efficacious (hair-bearing area) or safe for use (sensitive skin of the labia prone to burning). However, Cyclosporine is Food and Drug Administration (FDA)-approved for psoriasis, and is therefore an appropriate alternative to the requested Cosentyx for this particular patient at this time. Cyclosporine is not noted to have any increased risk of canker sores, either causing or aggravating these painful lip/oral lesions. Therefore, cyclosporine should be considered as a medically appropriate and indicated treatment at this immediate time.
Modern dermatology literature [1-4] supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Cosentyx, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Cosentyx is not medically necessary.