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202207-151584

2022

Fidelis Care New York

Medicaid

Skin Disorders

Pharmacy/ Prescription Drugs

Medical necessity

Overturned

Case Summary

Diagnosis: Psoriasis.
Treatment: Ilumya.

The insurer denied Ilumya. The denial is overturned.

The patient is a male with psoriasis, treated with topical steroids, topical calcineurin inhibitors, Enbrel, Tremfya, and Cosentyx. The provider recommended Ilumya. The health plan requires use of preferred agents Humira and Siliq.

At issue is the medical necessity of Ilumya 100 milligrams (MG)/milliliter (ML) subcutaneous (SC) pre-filled syringe (SOSY).

The health plan's determination of medical necessity is overturned in whole.

Yes, the requested health service/treatment of Ilumya 100MG/ML SC SOSY is medically necessary for this patient.

Ilumya is an approved, appropriate, and effective medication for psoriasis. A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded.

Therefore, the requested health service/treatment of Ilumya 100MG/ML SC SOSY is medically necessary for this patient.

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