Diagnosis: Nasal Polyps.
Treatment: Xhance 93 (micrograms) MCG/ACT NA EXHU (actualized solution in sodium for aerosol spray).

The insurer denied coverage for Xhance 93 MCG/ACT NA EXHU. The denial is upheld.

Per the documentation submitted, it is stated that the patient has used several nasal steroid sprays to the point where the nasal septum was beginning to atrophy. There is a history of sinus surgery/polypectomy and multiple courses of antibiotics and steroids by mouth. The patient has anosmia (inability to sense odor). No polyps were noted on physical examination. Xhance and desloratadine were ordered. Labs for RAST (Radioallergosorbent test) and IgE (Immunoglobulin E) levels were ordered. A denial by the insurer was issued for Xhance stating that the patient has not had an adequate 12-week trial with both preferred agents at an optimized dose and claim records show filling fluticasone nasal spray on at least 3 occasions. An appeal was signed but not dated by the physician assistant. Another denial letter by Fidelis was sent related to a medical necessity denial for Xhance. The printed guidelines for Xhance approval were not provided but the global prescription criteria were referenced, "not taken or had a poor response to medications on the preferred list" (fluticasone and budesonide). It does not state that both medications must have been failed or that 2 medications had to be used simultaneously.

The patient has met the criteria of failing at least 1 formulary nasal steroid spray, but currently the patient has not been shown to have nasal polyps (on examination, endoscopy or radiology), which is the indication for Xhance. The reviewer therefore upholds the denial based on inadequate documentation of medical necessity.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Xhance 93 (micrograms) MCG/ACT NA EXHU is not substantiated.