Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Pharmacy/Prescription Drugs. 
The insure denied Dymista. 
The denial is upheld.

This is a female patient with a recommendation for Dymista by her provider for allergic rhinitis (AR). Appeal states that Flonase, Nasonex and azelastine have been used.
At issue is whether for the formulary drugs will be or has been ineffective, would not be as effective as the non-formulary drug or have adverse effects.

The health plan's determination is upheld in whole.

Flunisolide has not been ineffective, would be as effective as the non-formulary drug (Dymista), or would not have adverse effects.
The formulary drug, flunisolide, would be reasonable to try. Flunisolide would not be less effective. The appeal states that Flonase, Nasonex and azelastine have been used with an inadequate response.
"The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret or refer to a clinician who can perform and interpret, specific immunoglobulin E (IgE) (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy." "The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls in patients with AR who have identified allergens. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy." (Seidman, M.D., et al. 2015).
"Description: The Joint Task Force on Practice Parameters, which comprises representatives of the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), formed a workgroup to review evidence and provide guidance to health care providers on the initial pharmacologic treatment of seasonal allergic rhinitis in patients aged 12 years or older.
Recommendation 1: For initial treatment of seasonal allergic rhinitis in persons aged 12 years or older, routinely prescribe monotherapy with an intranasal corticosteroid rather than an intranasal corticosteroid in combination with an oral antihistamine. (Strong recommendation).
Recommendation 2: For initial treatment of seasonal allergic rhinitis in persons aged 15 years or older, recommend an intranasal corticosteroid over a leukotriene receptor antagonist. (Strong recommendation).
Recommendation 3: For treatment of moderate to severe seasonal allergic rhinitis in persons aged 12 years or older, the clinician may recommend the combination of an intranasal corticosteroid and an intranasal antihistamine for initial treatment." (Wallace, D.V., et al. 2017).
Therefore, flunisolide would be reasonable to try.
Flunisolide has not been ineffective, would be as effective as the non-formulary drug (Dymista), and would not have adverse effects.