Diagnosis: Alopecia universalis
Treatment: Olumiant 4mg
The insurer denied Olumiant 4mg.
The determination is upheld.

The patient has alopecia universalis. She has failed topical and intralesional steroids. She has had a partial response to Xeljanz. The prescriber is a dermatologist. The medication under review is Olumiant 4 milligrams (mg) tablet.

The requested health service/treatment of Olumiant 4 mg tablet is not medically necessary for this patient. There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Olumiant for this patient's condition as an accepted standard of practice in the United Stated (U.S.) prior to the standard alternatives. There is no documentation the patient has exhausted all standard options, and that it would therefore be medically necessary to start systemic treatment with Olumiant, which would carry a higher side effect profile. Within the peer-reviewed literature, there are other effective first-line treatment for the management of severe alopecia. (4)