Diagnosis: Psoriasis Vulgaris
Treatment: Cosentyx, pre-service
The insurer denied the Cosentyx, pre-service
The denial is upheld.

The patient is a male. He has a medical history of plaque psoriasis, body surface
area 41% (percent). He has tried and failed topical steroids, Humira, and Tremfya. There is no reason given for the appeal of the denial.

No, the use of Cosentyx is not medically necessary for this patient.

According to the documentation provided for review, the patient has not tried and
demonstrated an inadequate treatment response or intolerance to Otezla, Skyrizi,
and Stelara, which are supported as standard, first-line therapy options. There is no
documentation of elevated liver function tests, recurrent infections, or underlying
disease or malignancies that would contraindicate the use of the plan's preferred
biologics. Current medical literature corroborates the safety and non-inferior or
superior efficacy of these preferred medications in this clinical scenario. Therefore,
this request for Cosentyx is not medically necessary at this time.

Yes, the health plan did act reasonably, with sound medical judgment, and in the
best interest of the patient.