Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Ear/Nose/Throat/ Rhinitis/Nasal Inflammation
Treatment: Pharmacy/Prescription Drugs/Dymista

The heal plan denied Pharmacy/Prescription Drugs/Dymista.
The health plan's determination is overturned.

This is a female patient with a diagnosis of allergic rhinitis. There is a letter of appeal from the physician, that states she is providing further information regarding failed therapies. "She has been on Nasonex, Flonase, Rhinocort, Nasacort, Allegra, Xyzal, Zyrtec, Clarinex, Claritin ". The physician notes that the oral antihistamines sedate her, and nasal steroids do give her help but do not completely eliminate her symptoms and she wants to use Dymista because it is a locally delivered antihistamine with less sedation. There are no office medical records or further medical records.
At issue is the medical necessity of the requested prescription medication, Dymista.

The health plan's determination of medical necessity is overturned, in whole.

The physician makes clear that this client has tried many and multiple therapies for her allergic rhinitis. These therapies have not been effective or are insufficiently effective. She has been on 4 different nasal steroids including flunisolide, Flonase, Rhinocort, Nasacort. Additionally, she states that she been on 6 different antihistamines including but not limited to Allegra, Xyzal, Zyrtec, Clarinex, and Claritin. She has intolerance to oral antihistamines due to sedation. The physician notes the nasal steroids give some help but are not sufficient alone. This means that the formulary or nonformulary nasal steroids are insufficient or are not as effective as a nonformulary combination. In particular, she cannot tolerate oral antihistamines, but she has a need for antihistamines. The most effective way to deliver her needed medication would be a combination of a nasal spray that has both a steroid and an antihistamine and Dymista fulfills this. Therefore, it can be stated this is all consistent with the formulary drug being ineffective and or not as effective as a non-formulary drug, and additionally she has adverse effects with an oral antihistamine.
This client has tried many different nasal steroids and antihistamines and her physician notes that she has "tried a least 6 "antihistamines and lists for nasal steroids so therefore she is used 10 different medications. The medications have not been sufficient, and it is reasonable to state that the attempt to use 10 different medications is a substantial attempt to fulfill any requirements. These medications have failed to resolve her symptoms and because she cannot tolerate oral antihistamines it is reasonable for her to use an antihistamine spray in combination with a steroid spray. The use of Dymista fulfills this and is medically necessary and appropriate.  (Triamcinolone with Azelastine are listed as an alternative but this client has had partial success with Fluticasone/Flonase and since Dymista contains Fluticasone and Azelastine it is reasonable for her to use the medication that has already partially helped her in combination with another medication meaning the Azelastine as opposed to using the Triamcinolone/Azelastine combination).