Diagnosis: Psoriasis.
Treatment: Stelara.

The insurer denied Stelara. The health plan's determination is upheld.

The patient is a male with psoriasis throughout his body (at least 20% body surface area involvement, and including the groin and scalp), as well as psoriatic arthritis of the hands and wrists. The patient has tried and failed high-potency topical steroids and calcipotriene, ultraviolet B (UVB) light therapy and Otezla. The patient has responded well to Stelara, and health plan coverage of Stelara therapy is under review.

Stelara is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to standard, first-line systemic therapies such as either Methotrexate (the standard first-line therapy for both moderate-severe psoriasis and for psoriatic arthritis), Acitretin (beneficial for the skin but not for the joints), and/or Phototherapy (helpful for psoriasis to non-sensitive areas, but not for the joints). Particularly for a patient with a limited history of systemic psoriasis and psoriatic arthritis therapy previously utilized, these preferred agents are appropriate for this patient's clinical scenario. Therefore, the requested Stelara is not medically necessary.