Xolair — Cigna

Chronic Rhinosinusitis with Nasal Polyps

Initial criteria

Patient age ≥ 18 years; AND
Diagnosis of chronic rhinosinusitis with nasal polyps as evidenced by exam, endoscopy, or CT scan; AND
Patient has experienced two or more of the following symptoms for ≥ 6 months: nasal congestion, obstruction, discharge, and/or loss of smell; AND
Baseline immunoglobulin E (IgE) level ≥ 30 IU/mL prior to Xolair or other monoclonal antibody therapy; AND
Patient meets BOTH of the following: a) received ≥ 4 weeks of intranasal corticosteroid therapy; AND b) will continue intranasal corticosteroid with Xolair; AND
Patient meets ONE of the following: a) received ≥ 1 course of systemic corticosteroid for ≥ 5 days in previous 2 years; OR b) has contraindication to systemic corticosteroid; OR c) had prior surgery for nasal polyps; AND
Medication prescribed by or in consultation with allergist, immunologist, or otolaryngologist.

Patient has already received ≥ 6 months of therapy with Xolair; AND
Patient continues to receive an intranasal corticosteroid; AND
Patient has responded to therapy as determined by prescriber (e.g., reduced nasal polyp size, improved congestion, reduced sinus opacification, improved smell).

initial 6 months; reauth 1 year