Diagnosis: Asthma.
Treatment: Fasenra.
The insurer denied coverage for Fasenra.

The denial is overturned.

The patient has severe persistent asthma on triple therapy with Advair, Spiriva and Albuterol as needed. The patient was also taking Prednisone as her asthma was poorly controlled. The patient was taking Montelukast and anti-allergic medication, Claritin, in addition. The patient was initiated on Macrolides three times a week. The patient was started on Fasenra for uncontrolled symptoms despite aggressive therapy.

Fasenra is indicated in severe uncontrolled Asthma. It is an IL5 (Interleukin 5) receptor Monoclonal Antibody. Usual Dosing schedule for Fasenra is 30 milligrams (mg) every 4 weeks for 3 cycles and subsequently 30 mg every 8 weeks. After starting on Fasenra the patient's symptoms improved and she was able to decrease her steroid dosing.

As per the physician's notes after switching administration from monthly to every 8 weeks the patient started to have return of significant symptoms after 4 weeks and started requiring Prednisone dosing with frequent exacerbations requiring Nebulizer therapy and frequent office visits. As per office visit the patient was having significant increase in her asthma symptoms. She was restarted on Prednisone 80 mg/day and was receiving nebulizers every 2 hours.

Given the fact that the patient had improved significantly while taking Fasenra every 4 weeks and on changing her to every 2-month regimen her symptoms worsened after 4 weeks with requirement of systemic steroids in high doses and with frequent nebulizer use.

This patient had severe persistent asthma and was showing significant improvement on Fasenra when it was being given every week. She started getting breakthrough symptoms at 4 weeks when 8 weeks regimen was tried.

Based on above and documentation provided by her doctor she should continue to receive Fasenra every 4 weeks for some more time until better control is achieved.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the medication Fasenra every 4 weeks is substantiated. The insurer's denial is overturned.