Diagnosis: Psoriasis
Treatment: Otezla
The insurer denied the Otezla.
The determination is upheld.

The patient has psoriasis. She also has psoriatic arthritis. She has failed tacroliomus ointment and betamethasone cream, clobetasol solution. The medication under review is Otezla.

The requested health service/treatment of Otezla is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred treatments methotrexate and cyclosporine, which have been shown to be effective for psoriasis.

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as methotrexate are effective treatments for the management of psoriasis (1, 2).

Within the peer-reviewed literature, West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2 percent (%) [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (3).

The evidence-based literature is consistent. The preferred agent methotrexate is appropriate for the treatment of the patient's psoriasis. Methotrexate should be tried and failed prior to initiating Otezla.

It is noted that the patient has tried and failed tacrolimus ointment. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Otezla prior to the formulary alternatives such as methotrexate.