How to Appeal a Humana Dupixent (dupilumab) injection - Pharmacy Coverage Policy Denial

What Humana requires for coverage

Humana considers Dupixent (dupilumab) injection - Pharmacy Coverage Policy medically necessary when the following criteria (from Dupixent-PA-Medicare) are met:

• {'indication': 'Atopic Dermatitis', 'criteria': ['Diagnosis of moderate to severe Atopic Dermatitis (e.g. erythema, moderate to severe induration/population, frequent to incessant itching, frequent to nightly loss of sleep)', 'Member must be 6 months of age or older', 'Previous treatment with, intolerance or contraindication to one high potency topical corticosteroid (e.g. augmented betamethasone dipropionate 0.05%, clobetasol cream/ointment, triamcinolone acetonide 0.5%) OR one topical calcineurin inhibitor (pimecrolimus cream or tacrolimus)']}
• {'indication': 'Moderate-to-severe Asthma (eosinophilic or oral corticosteroid dependent)', 'criteria': ['Diagnosis of moderate-to-severe asthma AND eosinophilic phenotype (blood eosinophils >= 150 cells/uL at initiation OR >= 300 cells/uL in previous 12 months) OR oral corticosteroid-dependent asthma', 'Unable to achieve adequate control while on maximum tolerated inhaled corticosteroid therapy in combination with a long acting beta agonist (e.g., formoterol)']}
• {'indication': 'Chronic Rhinosinusitis with Nasal Polyposis', 'criteria': ['Diagnosis of Chronic Rhinosinusitis with Nasal Polyposis', 'Member must be 12 years of age or older', 'Dupixent will be used in conjunction with a daily intranasal corticosteroid spray', 'Unable to achieve adequate control of symptoms with maximum tolerated intranasal corticosteroid therapy']}
• {'indication': 'Eosinophilic Esophagitis (EoE)', 'criteria': ['1 year of age or older', '15 kg (33lb) or higher', 'Diagnosis of EoE identified by endoscopic biopsy with peak cell count >= 15 eosinophils per high power field in 2 or more biopsied esophageal regions', 'Two or more episodes of dysphagia per week', 'Unable to achieve adequate control with one guideline directed therapy (e.g. generic high-dose proton pump inhibitor or topical corticosteroid)']}
• {'indication': 'Prurigo Nodularis', 'criteria': ['Diagnosis of Prurigo Nodularis', '18 years of age or older', 'Prescribed by or in consultation with a dermatologist, allergist, or immunologist']}
• {'indication': 'COPD with eosinophilic phenotype', 'criteria': ['Diagnosis of COPD', 'Eosinophilic phenotype: elevated peripheral blood eosinophil level >= 300 cells/uL in previous 12 months', '18 years of age or older', 'Unable to achieve adequate control on ICS+LABA+LAMA OR LABA-LAMA if ICS contraindicated']}
• {'indication': 'Chronic Spontaneous Urticaria (CSU)', 'criteria': ['Diagnosis of chronic spontaneous urticaria', '12 years of age or older', 'Remained symptomatic despite at least 2 weeks of H1 antihistamine therapy (unless contraindicated)', 'Will continue to receive H1 antihistamine therapy while on Dupixent (unless contraindicated)']}
• {'indication': 'Bullous Pemphigoid', 'criteria': ['Diagnosis of bullous pemphigoid confirmed by biopsy or serologic tests', '18 years of age or older', 'Prescribed by or in consultation with a dermatologist, allergist, or immunologist', 'Previous treatment with, intolerance or contraindication to one high potency topical corticosteroid OR oral corticosteroid (e.g. prednisone)']}

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the Dupixent-PA-Medicare language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Humana either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.

Source: Humana medical policy Dupixent-PA-Medicare — view the published policy.