Diagnosis: Psoriasis.
Treatment: Taltz.
The insurer denied coverage for Taltz.
The denial is overturned.

The patient is an adult with a diagnosis of psoriasis and psoriatic arthritis. The patient has a long history of severe disease which has failed therapy with methotrexate, Enbrel, Humira, and Cosentyx. The patient was started on Taltz with improvement, but not resolution. The physician added Otezla 30 mg (milligram) tablets twice daily (bid). The request is for continuation of Taltz in combination with Otezla.

Based on the submitted documentation, the use of Taltz and Otezla is medically necessary. The patient has severe psoriasis and psoriatic arthritis which has been resistant to numerous therapies. The patient previously required methotrexate in combination with etanercept. The patient has failed monotherapy with numerous biologics. The use of Otezla in combination with Taltz has provided symptomatic disease state relief for his conditions without noticeable side effects. The use of this combination is approved under the direction of the supervising dermatologist.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Taltz is substantiated.