Diagnosis: Plaque Psoriasis.
Treatment Cosentyx.
The insurer denied coverage for Cosentyx.
The denial is overturned.

The patient has a history of psoriasis, PsA (psoriatic arthritis), kidney stones and diabetes mellitus. The office visit notes from Rheumatology specialist the patient was doing well on a regimen of Cosentyx 300 milligrams (mg) every 14 days, Xeljanz currently 5 mg daily [half the usual dose], prednisone 5 mg daily and cyclosporine 100 mg twice daily. The patient's plaque psoriasis was dramatically improved on this combination. He was on a similar regimen.

According to the submitted documentation the patient has been on Cosentyx every two weeks, Xeljanz 5 mg QD [per day], cyclosporipn and prednisone with good control of skin and PsA. The insurer is denying Cosentyx because it should not be used with Xeljanz. The doctor argued that if Cosentyx is given 300 mg. every 2 weeks (presumably) instead of every 4, Xeljanz would not be needed.

The FDA [Food and Drug Administration] approved use of Xeljanz for psoriasis and PsA states that using it with biologics or cyclosporin is not recommended. The dose of Cosentyx 300 mg every two weeks is off-label and not addressed in the www.uptoidate.com chapter "Treatment of Psoriatic Arthritis"). A recent study by Reich et al compared 300mg q2w[every two week] to q4w [every four week] dosing. They found that in patients with a partial response switching to q2w dosing "Significantly more patients with q2w vs. q4w dosing showed minimal disease activity ...nd improved quality of life (Dermatology Life Quality Index score 0 or 1: 58·9% vs. 50·6%, P < 0·05) at week 32. No new or unexpected safety signals arose."

There is support for the insurer's refusal to cover Cosentyx when used concomitantly with Xeljanz. He has been on Cosentyx twice a week without apparent toxicity and with good benefit. Using more Xeljanz would have to consider unknown interactions with biologics and cyclosporin. In addition, there is published support for using Cosentyx 300 mg SC [subcutaneous] every two weeks as requested by the physician.

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 Cosentyx is overturned. Medical is substantiated.