Diagnosis: nasal polyps
Treatment is Dupixent Syn 300
The insurer denied coverage for Dupixent Syn 300
The denial is overturned

This is an adult male with a long history of nasal polyps refractory to medical and surgical interventions. A medical note documented the following: "This patient has massive polyps completely including both of his nasal cavities, he already has had multiple surgeries and has had multiple rounds of oral steroids and the polyps persist. Looking inside of his nose on routine rhinoscopy reveals complete occlusion of the nasal cavity by his polyps."

The insurers criteria for reimbursement for Dupixent therapy as is:

"...current plan approved criteria only allow coverage of Dupixent if the patient had polyps reaching below the lower border of the middle turbinate or beyond in each nostril."

This patient fulfills these criteria as his nasal polyps were documented to be beyond the lower border of the middle turbinate in both nostrils.

Dupixent Syn 300 is considered medically necessary for this patient as documented in the peer reviewed literature (1-4) and that the patient fulfilled the insurers criteria for Dupixent therapy. Dupixent has been approved by the FDA (food and drug administration). The peer reviewed literature attests to the efficacy of Dupixent therapy for nasal polyps1-4. This patient fulfills the insurers criteria as his nasal polyps were documented to be beyond the lower border of the middle turbinate in both nostrils.

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

The insurer's denial of coverage for Dupixent Syn 300 is overturned. Medical Necessity is substantiated.