
202204-148035
2022
Excellus
PPO
Ears/ Nose/ Throat
Pharmacy/ Prescription Drugs
Medical necessity
Overturned
Case Summary
Diagnosis: Chronic Sinusitis.
Treatment: Dupixent.
The insurer denied Dupixent. The health plan's determination is overturned.
The patient is a male with a history of nasal polyposis, anosmia, chronic sinusitis, allergic rhinitis, and asthma. Past surgical history was significant for septoplasty and endoscopic sinus surgery. Previous allergy testing was performed. He is currently on immunotherapy.
Past medical treatment was significant for topical budesonide, but the patient continued to have progressive nasal polyp issues. The patient was unable to continue antihistamines, azelastine, and Singulair under the direction of his urologist. He did continue with the Dupixent and a topical steroid (budesonide rinses).
Dupixent 300mg syringe is medically necessary for the patient. Current community standards for the use in Dupixent in the patient population with chronic sinusitis with nasal polyposis suggest that patients should fail conventional medical therapy prior to the use of monoclonal antibodies. In the case of this patient who has undergone prior surgical therapy in addition to topical steroids (Budesonide) and immunotherapy, Dupixent is medically necessary. There is no consensus in the community otolaryngologists that patients should be on mometasone prior or during Dupixent usage. This patient has responded well to Dupixent with decrease/stability of nasal polyps. Current practice-based evidence suggest that this patient should continue with the Dupixent therapy.