CurrentCignaPolicy IP0274

Nasal steroids and nasal steroid/antihistamine combination products

Defines medical necessity criteria, continuation, authorization durations, and non-covered uses for prescription nasal corticosteroids and nasal steroid/antihistamine combination products for Cigna-administered plans. Notes that coverage varies by specific benefit plan and some employer plans exclude nasal steroids.

Policy Summary

PayerCigna

PolicyNasal steroids and nasal steroid/antihistamine combination products

Policy CodePolicy IP0274

Change TypeRevised preferred product criteria for Xhance

Effective DateJan 15, 2025

Next Review Date

Key ActionProvide documentation that the member has tried the specified alternatives (or has contraindication/intolerance) when requesting coverage; note that OTC nasal steroids may count as a trial.

POLICY UPDATE CHANGES

Updated preferred product criteria for Xhance: removed age and specialist-prescriber requirements and changed to require trials of flunisolide, fluticasone, and mometasone; added note that OTC nasal steroids count as a trial.

MultipleCovered Indications (by product)

12 monthsInitial Authorization Duration

12 monthsReauthorization Duration

Some EGPsBenefit Variability/Exclusions

Coverage Summary

Defines medical necessity criteria, continuation, authorization durations, and non-covered uses for prescription nasal corticosteroids and nasal steroid/antihistamine combination products for Cigna-administered plans. Coverage varies by specific benefit plan and some employer plans exclude nasal steroids.

Subject: Nasal steroids and nasal steroid/antihistamine combination products. This policy describes medical necessity criteria for prescription nasal corticosteroids and nasal steroid/antihistamine combinations for health benefit plans administered by Cigna Companies and notes that coverage varies by customer benefit plan; some Employer Group Plans specifically exclude nasal steroids.

Key policy summary

Covered Indications (by product)Multiple branded products with product-specific criteria

Initial Authorization DurationInitial approval up to 12 months

Reauthorization DurationReauthorization up to 12 months

Benefit Variability/ExclusionsCoverage varies by plan; some Employer Group Plans specifically exclude nasal steroids

Effective Date2025-01-15

Product-specific Medical Necessity Criteria

Xhance (fluticasone propionate) 93mcg/spray

Xhance is considered medically necessary when the following documentation is provided:

Revision removed requirement for age and specialist prescribing; added note that OTC nasal steroids would count as a trial of an alternative.

Provider Actions & Denial Risk

Prior Authorization

Medical necessity documentation required for non-preferred products

Coverage requires documentation meeting the listed criteria (failure/contraindication/intolerance to specified alternatives or inability to take bioequivalent generic due to inactive ingredient differences); receipt of sample product does not satisfy criteria.

Receipt of sample product does not satisfy criteria.

Documentation Required

Continuation of therapy documentation

Reauthorization requires documentation of beneficial response and that initial criteria are still met.

Billing Rule

Authorization duration

Initial and reauthorization approval durations are up to 12 months.

Denial Risk

Not medically necessary for other uses

Nasal steroids and nasal steroid/antihistamine combinations are considered not medically necessary for any other use beyond the listed indications; claims for other uses may be denied.

Documentation Required

OTC products counting as trial

For Xhance, an OTC nasal steroid can count as a trial of an alternative (must be documented).

Background

Policy supports medical necessity review for prescription nasal corticosteroids and nasal steroid/antihistamine combinations. Coverage for these products varies across customer benefit plans and requires use of preferred products when applicable; some Employer Group Plans specifically exclude nasal steroid therapy.

Xhance is indicated for the treatment of chronic rhinosinusitis (CRS) with or without nasal polyps in adults and utilizes an OptiNose Exhalation Delivery System (EDS), a bi-directional delivery system that differs from traditional nasal sprays. The Xhance preferred-product criteria were revised to remove prior age and specialist-prescriber requirements and now require documentation that the patient has tried flunisolide 25mcg/spray nasal solution, fluticasone 50mcg/spray nasal suspension, and mometasone furoate 50mcg/spray nasal suspension; the revision also specifies that OTC nasal steroids count as a trial of an alternative.

Failure, contraindication, or intolerance: Clinical documentation that the member did not respond to, cannot take, or has an adverse reaction to the listed alternative product(s).

Revision History

2025-01-15revisedLatest

Updated preferred product criteria for Xhance: removed age (≥18) and specialist-prescriber (prescribed by or in consultation with allergist/immunologist/ENT) requirements; changed requirement to documentation that patient has tried all three listed agents (flunisolide 25mcg/spray nasal solution, fluticasone 50mcg/spray nasal suspension, and mometasone furoate 50mcg/spray nasal suspension); added note that over-the-counter (OTC) nasal steroids would count as a trial of an alternative.