Diagnosis: Plexiform Neurofibroma
Treatment: Koselugo 25MG (milligrams) OR (oral) CAPS (capsules), pre-service
The insurer denied the Koselugo 25MG OR CAPS, pre-service.
The denial is overturned.

The patient is a male with a history of a left orbit plexiform neuroma. The provider is recommending treatment with Koselugo 25 milligram (MG) OR (oral) CAPS (capsules).

Yes, the proposed treatment with Koselugo is medically necessary.

Plexiform neurofibromas occur in up to 30% (percent) of cases of neurofibromatosis type one (NF-1), most frequently in the craniomaxillofacial region. These lesions manifest early in life and tend to transform to malignant peripheral nerve sheath tumors (MPNST). Malignant progression is generally considered the main cause of mortality, occurring in two percent to 16% of cases.

Koselugo (selumetinib) is a selective and potent orally available non-ATP (adenosine triphosphate) competitive small molecule inhibitor of mitogen-activated protein kinase 1 and 2 (MEK1/MEK2). In a recent phase II study, 34 of 50 patients (68%) had a confirmed partial response, and 28 of these patients had a durable response (lasting one year).

Based on this data, Koselugo would be considered medically necessary for this patient.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The use of Koselugo for this indication is considered to be medically necessary and the standard of care.