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202201-145821

2022

CVS Caremark

Self-Funded

Immunologic Disorders

Pharmacy/ Prescription Drugs

Medical necessity

Overturned

Case Summary

Diagnosis: Severe Alopecia Areata

Treatment Xeljanz 10 mg (milligrams)

The insurer denied coverage for Xeljanz 10 mg (milligrams)

The denial is overturned

The patient is a has a diagnosis of severe alopecia areata affecting >50% (percent) scalp. The patient's past medical history is also significant for multiple autoimmune disorders. Including vitiligo and rheumatoid arthritis. The patient has failed therapy with topical, intralesional, and oral steroids. The dermatologist is requesting Xeljanz given the failure of the above therapies and considering her other autoimmune conditions.

The patient's alopecia areata is unlikely to react with great success to topical therapies and is thus severe enough to warrant systemic therapy. Given the co-existing conditions, rheumatoid arthritis, and vitiligo, which may also benefit from Xeljanz therapy it is within the standard of care to allow for the use of Xeljanz for the treatment of this patient's alopecia areata. As a result, the use of xeljanz is medically necessary for use in the treatment of the patient's condition.

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 Xeljanz 10 mg is overturned. Medical necessity is substantiated.

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