Diagnosis:
Skin Disorders
Treatment:
Pharmacy/ Prescription Drugs
Health Plan:
United Healthcare Ins. Co. of N.Y.
Decision:
Upheld upheld
Appeal Type:
Medical necessity
Gender:
Male
Age Range:
40-49
Decision Year:
2022
Appeal Agent:
IPRO
Case Number:
202204-148953
Summary

Diagnosis: Asteatotic eczema Treatment: Dupixent The insurer denied coverage for Dupixent The denial is upheld The patient has a diagnosis of asteatotic eczema. According to the documentation provided, he has failed topical therapy only with steroids (triamcinolone, fluocinonide, and clobetasol). The requested medication is Dupixent for the treatment. Based on the provided documentation, the requested medication, Dupixent, is not medically necessary for this patient's condition. There is no medical and scientific literature that strongly support the administration of Dupixent for this patient's condition and disease severity as an accepted standard of practice in the U.S. compared to alternative therapies. The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this particular individual in the documentation provided that would make it medically necessary. According to the dermatology literature, the conventional medications such as protopic, elidel, and (for moderate to severe disease) methotrexate are effective treatments for the management of atopic dermatitis (1,2). Although asteatotic eczema can be treated systemically with agents used for treatment of atopic dermatitis, there is no FDA (food and drug administration) approved indications for treatment of asteatotic eczema with Dupixent. Within the peer-reviewed literature, in 2018, Gerbens writes "MTX (methotrexate) and AZA (azathioprine) seem to be effective and safe as maintenance treatments in moderate to severe AD (atopic dermatitis) up to 5 years" (3). Shah 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk" (4). There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis (5-8). The conventional medications, such as protopic and elidel topically and/or systemic methotrexate, should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient according to the standard of care. The health plan acted reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for Dupixent to treat atopic dermatitis is upheld. Medical necessity is not substantiated.

References

1) Bolognia, J., Jorizzo, J. L., & Schaffer, J. V. (2017). Dermatology. Philadelphia: Elsevier Saunders. 2) Gerbens LA, Hamann SA, Brouwer MW, Roekevisch E, Leeflang MM, Spuls PI. Methotrexate and azathioprine for severe atopic dermatitis: a 5-year follow-up study of a randomized controlled trial. British Journal of Dermatology. 2018 Jun;178(6):1288-96. 3) Shah N, Alhusayen R, Walsh S, Shear NH. Methotrexate in the Treatment of Moderate to Severe Atopic Dermatitis: A Retrospective Study. Journal of cutaneous medicine and surgery. 2018 Sep;22(5):484-7 4) Schram ME, Roekevisch E, Leeflang MMG, Boos JD, Schmitt J. SpulsPI. A randomized trial of methotrexate versus azathioprine for severe atopic eczema. J Allergy Clin Immunol. 2011; 128:353-9. 5) Weatherhead SC, Wahie S, Reynolds NJ, Meggitt SJ. An open-label, dose-ranging study of methotrexate for moderate-to-severe adult atopic eczema. Br J Dermatol. 2007; 156:346-51. 6) Goujon C, Bérard F, Dahel K, et al. Methotrexate for the treatment of adult atopic dermatitis. Eur J Dermatol. 2006; 16:155-8 7) Lyakhovitsky A, Barzilai A, Heyman R, Baum S, Amichai B, Solomon M, Shpiro D, Trau H. Low-dose methotrexate treatment for moderate-to-severe atopic dermatitis in adults. J Eur Acad Dermatol Venereol. 2010; 24:43-9. 8) Schulz, P., et al. "Pimecrolimus cream 1% is effective in asteatotic eczema: results of a randomized, double-blind, vehicle-controlled study in 40 patients." Journal of the European Academy of Dermatology and Venereology 21.1 (2007): 90-94. 9) Specht, Shane, and Yudy Persaud. "Asteatotic Eczema." StatPearls [Internet]. StatPearls Publishing, 2021.