Diagnosis: Sjogren's Syndrome with Arthritis
Treatment: Rasuvo
The insurer denied: Rasuvo
The denial is: Upheld

The patient is a female with Sjogren's syndrome with arthritis. The issue in this case is Rasuvo is being denied by the health plan. The plan only covers Rasuvo if the patient is unable to give the generic injections to themselves. The patient's prior treatment includes oral methotrexate (MTX), which she was unable to tolerate due to gastrointestinal (GI) side effects. Prior treatment also includes Plaquenil, prednisone, Cymbalta, Mobic, diclofenac, and gabapentin. The subject under review is the medical necessity for Rasuvo for this patient.

Rasuvo is not medically necessary. There is no medical reason she cannot try the generic subcutaneous (SQ) methotrexate which is the plan preferred drug.
The patient has Sjogren's and the main issue at present is ongoing arthritis. She has already tried oral MTX (unable to tolerate due to GI side effects), Plaquenil, prednisone, Cymbalta, Mobic, diclofenac and gabapentin. A trial of SQ MTX is very reasonable to treat her arthritis but she does not have a contraindication or side effect to generic SQ MTX. A study in Arthritis and Rheum in 2008 looking at patients with rheumatoid arthritis (RA) on MTX, concluded that, "this 6-month prospective, randomized, controlled trial is the first to examine oral versus SQ administration of MTX. We found that SQ administration was significantly more effective than oral administration of the same MTX dosage. There was no difference in tolerability."