Diagnosis: Psoriasis.
Treatment: Taltz.

The insurer denied Taltz.
The determination is upheld.

The patient is a male with psoriatic arthritis and moderate to severe psoriasis (40% (percent) body surface area involvement) of the malar area, nasolabial folds, eyebrows, ears, trunk, elbows, hands, and lower extremities. At issue is the medical necessity of Taltz.
Taltz is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to, either Cimzia, Humira, Skyrizi, Stelara, or Tremfya, all of which are of similar potency and efficacy to the requested Taltz. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition as is the requested Taltz. Therefore, Taltz is not medically necessary.