Diagnosis: Skin Disorders/Other/Atopic Dermatitis
Treatment: Dupixent
The health plan denied Dupixent, as not medically necessary.
The health plan's determination is upheld.

The patient is a male with atopic dermatitis. Per the appeal letter, he has tried and failed Betamethasone, Mometasone, Triamcinolone, and Clobetasol. He has also failed Halobetasol and Tacrolimus. However, no clinical documentation of failure with Tacrolimus ointment is provided.
The medication under review for medical necessity is Dupixent.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service/treatment of Dupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as Tacrolimus ointment, are effective treatments for the management of atopic dermatitis. [1,2]
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, Tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults." [3]
It is noted that the patient has tried and failed topical steroids. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents, such as Tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent.
Therefore, Dupixent is not medically necessary for this patient.