Diagnosis: Polyarticular Juvenile Idiopathic Arthritis (JIA).
Treatment: Weekly Humira.
The insurer denied: Weekly Humira.
The denial is: Overturned.

The patient is a female who has polyarticular juvenile idiopathic arthritis (JIA) and has been on Humira every 14 days, however, has subtherapeutic Humira levels and continues to have inflammation in the joints. The patient has been prescribed Humira every week however it was denied. The patient is not able to take methotrexate. The subject under review is the medical necessity for weekly Humira for this patient.

The health plan's determination is overturned.

Treatment with Humira weekly is medically necessary for this patient. It is Food and Drug Administration (FDA) approved weekly for rheumatoid arthritis. It is standard of care to use this medicine weekly when every other week is not effective. JIA is also an inflammatory arthritis, and this medicine can be used weekly. Those who do not respond to every other week Humira are placed on weekly medication. This is medically necessary for this patient.
Per Wolf, et al. Escalation to weekly adalimumab dosing demonstrated clinical benefits for patients who lost response to therapy and may be beneficial for patients not initially responding to induction therapy. No new safety risks were identified with weekly dosing.
Per Leonardi et al. By 12 weeks after dose escalation, one-quarter achieved substantial clinical improvement. Safety results were similar between patients who dosage-escalated and those who did not.