Asthma Rx denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Xolair injections. A review of the records indicates the enrollee has moderate to severe asthma. His environmental triggers include grass, hay, pollen, dust, cats, smoke, perfumes, feathers and cold and damp weather. He had an elevated immunoglobulin E (IgE) level and was using a Symbicort inhaler daily to treat his asthma condition. He started receiving Xolair injections. He also tried antihistamines and nasal sprays to control his symptoms. His physician indicated he has a history of frequent exacerbations, which require urgent care visits and the use of oral steroids for acute exacerbations. Notes indicate his symptoms had improved significantly while on Xolair and he was using his Symbicort inhaler only once a day.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Xolair. Researchers report that allergic bronchopulmonary aspergillosis (ABPA) is a common complication that affects up to 15% of patients with cystic fibrosis. ABPA may lead to an accelerated decline in lung function if untreated thus appropriate and timely treatment is imperative. The authors further note that corticosteroids are used as first-line therapy, but relapse and adverse effects commonly occur. Prolonged use of systemic steroids, such as prednisolone, for ABPA may result in significant systemic side effects such as glucose intolerance, decreased bone density, and linear growth retardation.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucala auto-injector 100 mg/mL subcutaneously. According to the U.S. Food and Drug Administration (FDA), Nucala is approved for use as add-on maintenance treatment of adult and pediatric patients aged six years and older with severe asthma and with an eosinophilic phenotype. There is a lack of report of recent hospitalizations, nighttime awakenings, or emergency department evaluations to determine the severity of patient’s asthma. According to the Global Initiative for Asthma (GINA), severe asthma is a subset of difficult-to-treat asthma that is defined as asthma that is uncontrollable despite medium or high-dose inhaled corticosteroids with a second controller, such as a long-acting beta agonist or maintenance oral corticosteroid therapy, to maintain symptom control.

Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage of Symbicort inhaler for asthma with symptoms of shortness of breath, coughing spasms, and tightness in her throat. She also has environmental allergies for which she takes antihistamine medication and a nasal spray. The enrollee reports she has tried multiple inhalers, steroids, and antibiotics to control her asthma symptoms. Her allergist noted poorly controlled, moderate persistent asthma and a chronic cough as a result, and ordered Symbicort. Her primary care provider noted her asthma was stable with Symbicort and Albuterol, as needed. The enrollee returned with an upper respiratory infection and reported that she had tried to refill her Symbicort, but the pharmacist gave her Dulara, which she had failed. A new authorization for Symbicort was submitted and denied.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Asthma Rxwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.