Diagnosis: Alopecia Areata Treatment: Xeljanz XR 10mg Tab, Pre-service The insurer denied the Xeljanz XR 10mg Tab, Pre-service. The denial is overturned. The patient is a female with severe alopecia areata and vitiligo. She has severe eye irritation from lack of eyelashes and eyebrows. She has failed topical, intralesional, and systemic steroids, as well as topical calcineurin inhibitors. She has been on tofacitinib ten milligrams (mg), twice daily, for six weeks and continues to lose hair. Yes, the proposed Xeljanz is medically necessary. The current literature reflects Xeljanz as being more effective than other treatments. Alopecia areata (AA) is a relatively common disease, but no satisfactory treatment has yet been developed. Recently, research progress has been made in the pathogenesis of alopecia areata, revealing that autoreactive cytotoxic T cells are important and that the Janus kinase (JAK) pathway is involved. Therefore, the potential of Janus kinase (JAK) inhibitors as therapeutic agents for alopecia areata is attracting attention. There have been a number of case reports and small clinical trials reporting promising outcomes of Janus kinase (JAK) inhibitors tofacitinib, ruxolitinib and baricitinib for alopecia areata. The majority of the literature to date is based on small volume data, with a lack of definitive evidence or guidelines. A retrospective study of 90 adults with severe alopecia areata (at least 40 percent scalp hair loss, alopecia totalis, or alopecia universalis) who had stable or worsening disease for at least six months and received oral tofacitinib (five to ten milligrams [mg] twice daily) for at least four months (with or without adjuvant prednisone) supports benefit. Of the 65 patients with a duration of the current disease episode of ten years or less, 77 percent had a clinical response (at least six percent improvement in the Severity of Alopecia Tool [SALT] score) and 58 percent achieved greater than 50 percent improvement in the Severity of Alopecia Tool (SALT) score over four to 18 months of treatment. Patients with a disease episode longer than ten years appeared less likely to respond to treatment; the clinical response rate in this population was 32 percent (eight of 25 patients). No serious adverse effects occurred during treatment. Therefore, given the above, Xeljanz is the best treatment option for this patient at this time. Treatment with Xeljanz is currently the best treatment option for this patient at this time. Given this patient's diagnosis and history, treatment with Xeljanz would be considered to be reasonable and consistent with the current standard of care in the dermatology community.

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