Diagnosis: Pseudogout

Treatment: Kineret 100 mg (milligrams)/0.67

The insurer denied coverage for Kineret 100 mg (milligrams)/0.67

The denial is overturned


According to the medical records, this is an adult female patient has a history of pseudo gout along with chronic arthritis. She has tried and failed treatment with non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, methotrexate, Arava, Otezla, Enbrel and Cosentyx. The patient complains of morning stiffness, lasting about an hour.

The patient has a diagnosis of pseudo gout as well as chronic arthritis with recurrent and disabling flares. She has tried and failed multiple medications that include with non-steroidal anti-inflammatory drugs (NSAIDs), Arava, Otezla, Enbrel, Methotrexate, Colchicine and Cosentyx. Studies have shown that Kineret (Anakinra) has been helpful in these types of cases.

Kineret 100 mg (milligrams)/0.67 Syringe is considered medically necessary for this patient.

Per American College of Rheumatology (2019),"Anakinra is FDA approved to treat rheumatoid arthritis and neonatal-onset multisystem inflammatory disease (NOMID). Although not an FDA (Food and Drug Administration)-approved indication, anakinra is sometimes used to treat systemic juvenile idiopathic arthritis (SJIA), Adult-Onset Still's Disease (AOSD), gout, calcium pyrophosphate deposition (CPPD)(formerly called Pseudogout), Behcet's Disease, ankylosing spondylitis, uveitis, and other auto-inflammatory syndromes."

"Efficacy of anakinra was shown to be non-inferior to treatment as usual for the treatment of acute gout flares, suggesting that anakinra is an effective treatment alternative for acute gout flares." (Janssen, C. A., et al., 2019).

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 Kineret 100 mg (milligrams)/0.67 Syringe services is substantiated.