This is a patient with a medical history of Samter's Triad (asthma, chronic rhinosinusitis and aspirin sensitivity) who has tried and failed Asmanex and Qvar Redihaler for the chronic rhinosinusitis and is currently on therapy with Xhance with good efficacy. The issue for review is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug or would have adverse effects.
The health plan's determination is overturned.
The formulary drugs have been ineffective and have not been as effective as the non-formulary drug and have caused adverse effects.
Per the clinical information provided, the patient has a diagnosis of Samter's Triad, which is a condition defined by asthma, sinus inflammation with recurring nasal polyps (chronic rhinosinusitis), and aspirin sensitivity. The provider is requesting Xhance, a nasal corticosteroid for the treatment of the patient's chronic rhinosinusitis associated with this condition. Intranasal glucocorticoids are the cornerstone of maintenance treatment for chronic rhinosinusitis. Per the clinical documentation from the provider, the patient has tried and failed both Asmanex and Qvar Redihaler; he was unable to tolerate them due to side effects.