How to Appeal a Anthem Blue Cross Blue Shield Dupixent (dupilumab) - Medical Drug Clinical Criteria Denial

What Anthem Blue Cross Blue Shield requires for coverage

Anthem Blue Cross Blue Shield considers Dupixent (dupilumab) - Medical Drug Clinical Criteria medically necessary when the following criteria (from CC-0029) are met:

• {'indication': 'Asthma - Initial Request', 'criteria': ['Individual is 6 years of age or older', 'Individual has a diagnosis of moderate-to-severe asthma: (A) Pretreatment FEV1 <= 80% predicted, AND (B) FEV1 reversibility of at least 12% and 200 mL after albuterol', 'One of the following: (A) Blood eosinophil count >= 150 cells/microliter at initiation of therapy AND 3-month trial and inadequate response or intolerance to combination controller therapy (high dose ICS plus LABA, leukotriene modifiers, theophylline, or oral corticosteroids); OR (C) Oral corticosteroid dependent asthma AND (D) 3-month trial and inadequate response or intolerance to high dose ICS with daily oral glucocorticoids plus controller medication', 'Two or more asthma exacerbations in prior 12 months requiring systemic corticosteroid use or temporary increase in maintenance oral corticosteroid dosage'], 'approval_duration': 'Initial: 6 months'}
• {'indication': 'Asthma - Continuation', 'criteria': ['One or more of: (A) Decreased utilization of reliever medications, OR (B) Decreased frequency of exacerbations, OR (C) Increase in predicted FEV1 from pretreatment baseline, OR (D) Reduction in reported asthma-related symptoms', 'Individual continues to use Dupixent in combination with inhaled corticosteroid-based controller therapy'], 'approval_duration': 'Continuation: 12 months'}
• {'indication': 'Atopic Dermatitis - Initial Request', 'criteria': ['Individual is age 6 months or older', 'Individual has a diagnosis of moderate to severe atopic dermatitis', 'Individual has tried one of the following and treatment failed to achieve and maintain remission of low or mild disease activity: (A) Topical calcineurin inhibitors, OR (B) Eucrisa, OR (C) Opzelura, OR (D) Zoryve 0.15% Cream, OR (E) Phototherapy (UVB or PUVA), OR (F) Non-corticosteroid systemic immunosuppressants (cyclosporine, azathioprine, methotrexate, or mycophenolate mofetil), OR (G) Individual has contraindications to ALL of the above'], 'approval_duration': 'Initial: 6 months'}
• {'indication': 'Atopic Dermatitis - Continuation', 'criteria': ['Treatment with Dupixent has resulted in significant improvement or stabilization in clinical signs and symptoms (including decrease in affected body surface area, pruritus, severity of inflammation, and/or improved quality of life)'], 'approval_duration': 'Continuation: 12 months'}
• {'indication': 'Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) - Initial Request', 'criteria': ['Individual is age 18 years and older', 'Diagnosis of CRSwNP confirmed by: (A) Anterior rhinoscopy, OR (B) Nasal endoscopy, OR (C) Computed tomography (CT)', 'Recent trial and inadequate response to maintenance intranasal corticosteroids', 'Trial and inadequate response or intolerance to one of: (A) Systemic corticosteroids, OR (B) Sino-nasal surgery; OR has contraindications to both', 'Requesting Dupixent as add-on therapy to maintenance intranasal corticosteroids'], 'approval_duration': 'Initial: 6 months'}
• {'indication': 'CRSwNP - Continuation', 'criteria': ['Treatment has resulted in confirmed clinically significant improvement or stabilization (including improvement in nasal polyp score or nasal congestion score)'], 'approval_duration': 'Continuation: 12 months'}
• {'indication': 'Eosinophilic Esophagitis (EoE) - Initial Request', 'criteria': ['Individual is 1 year of age or older and weighs at least 15kg', 'Diagnosis of EoE confirmed by: (A) 15 or more intraepithelial eosinophils per high-power field, AND (B) Symptoms of dysphagia', 'Individual has tried a course of proton pump inhibitors (PPIs)', 'Individual has tried a course of glucocorticoids (fluticasone propionate MDI swallowed or budesonide inhalation swallowed) for EoE'], 'approval_duration': 'Initial: 6 months'}
• {'indication': 'Prurigo Nodularis (PN) - Initial Request', 'criteria': ['Individual has a diagnosis of PN', 'Individual has 20 or more PN lesions', "Individual meets one of: (A) Tried at least 2-week course of medium to super-potent topical corticosteroids or such are not appropriate (lesions in sensitive areas, steroid-induced atrophy, history of long-term topical steroid use), OR (B) Tried 2-week course of topical calcineurin inhibitors and failed or not appropriate (history of malignant/pre-malignant skin conditions, Netherton's Syndrome, immunocompromised)"], 'approval_duration': 'Initial: 6 months'}

Covered procedure codes

J3590	Unclassified biologics [when specified as dupilumab (Dupixent)]
C9399	Unclassified drugs or biologicals [when specified as Dupixent]

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the CC-0029 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Anthem Blue Cross Blue Shield 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: Anthem Blue Cross Blue Shield medical policy CC-0029 — view the published policy.