Diagnosis: Immunologic Disorders/Alopecia areata, unspecified
Treatment: Pharmacy/Prescription Drugs/ Olumiant 25MR OR Tabs
The health plan denied the requested medication, Olumiant 25MR OR Tabs as not medically necessary.
The health plan's determination is upheld.

The patient is a female with alopecia areata. The patient was noted to have a 1-1.5 centimeter (cm) oval area with loss of hair, which was diagnosed as alopecia areata. The clinic note for that date reported improvement with topical augmented Betamethasone Dipropionate lotion.
Health plan coverage of Olumiant is under review for medical necessity.

The health plan denial of Olumiant coverage is recommended to be upheld.

No. Olumiant is only Food and Drug Administration (FDA) approved for moderate to severe alopecia areata in adults. This patient has very limited alopecia areata, and which appears to be improving, or at least is controlled, on topical steroids. The risks of use of this systemic treatment (Olumiant) by far outweigh any potential benefits--if any significant benefits are likely to be achieved that time and current treatment alone would otherwise perform.
The health plan only covers medications that are FDA-approved and evidence-proven for a given condition. Olumiant is FDA-approved for moderate to severe alopecia areata in adult patients (18 years of age or older). This patient has at best mild alopecia areata, which appears to be improving or controlled on topical steroids, and is by far too young to prove any safe indications for being treated with a medication with potential side effects and lab monitoring as exists with the Janus Kinase inhibitor Olumiant. The proper dosing for this patient is not known, and any benefits or favorable outcomes of Olumiant for this particular clinical scenario are also unknown. Olumiant is therefore not only not medically necessary, but is arguably entirely medically inappropriate with respect to safety issues in the treatment of this patient's mild alopecia areata.