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202205-149910

2022

Fidelis Care New York

Medicaid

Immunologic Disorders

Pharmacy/ Prescription Drugs

Medical necessity

Overturned

Case Summary

Diagnosis: Psoriatic Arthristis.
Treatment: Taltz.
The insurer denied the Taltz.
The denial is overturned.

The patient is a male diagnosed with psoriasis and psoriatic arthritis. He has tried and failed triamcinolone and was started on Taltz. The patient has been stabilized on Taltz so the treating provider has requested continuation of treatment with Taltz. The request was denied by the health plan so the provider is appealing the denial.

Yes, the proposed treatment with Taltz is medically necessary.
The patient 's primary diagnosis is psoriasis but he also has psoriatic arthritis and he has been stabilized on Taltz for three years. To change the patient's medication puts the patient at risk for destabilization. The suggested alternatives are not Food and Drug Administrative (FDA) approved for the treatment of both psoriasis and psoriatic arthritis and the patient has both diseases.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The treatment alternatives suggested by the plan are not Food and Drug Administrative approved to treat all of the patient's diagnoses. Standard of care would be to continue an effective treatment instead of changing to an off-label medication, risking destabilization of one or all of the patient's diagnoses.

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