CurrentColorado Rocky Mountain Health PlansPolicy N/A

Omalizumab (Xolair) for nasal polyps — prior authorization

Prior authorization form and criteria for initiating or continuing omalizumab (Xolair) to treat nasal polyps for Colorado Rocky Mountain Health Plans members in North Carolina. Affects prescribers requesting PA for adults with nasal polyps.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOmalizumab (Xolair) for nasal polyps — prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit PA form with beneficiary and prescriber details, weight, IgE level, confirmation of nasal polyps diagnosis, prior intranasal steroid trial and failure, and prescriber signature; attach records for continuation requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Minimum age for therapy

30–150 kgAllowed weight range

>30 IU/mlIgE threshold asked on form

365 DaysMax authorization option

Coverage Criteria for Omalizumab (Xolair) — Nasal Polyps

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Initial Therapy

Covered when ALL of the following are met

Age: Beneficiary is 18 years of age or older>=18 years

form asks whether beneficiary is 18 years or older

Weight: Beneficiary weighs between 30 kg (66 lbs) and 150 kg (330 lbs)30–150 kg

form asks whether beneficiary weight falls in this range; weight to be recorded if outside

IgE level: Beneficiary has an IgE level above 30 IU/ml (document level)>30 IU/ml

form asks whether IgE > 30 IU/ml and requests the numeric level

Diagnosis of nasal polyps documented

form asks to confirm diagnosis of nasal polyps

Prior therapy: Beneficiary has tried and failed monotherapy with intranasal (nasal) steroids

form asks whether beneficiary tried and failed nasal steroid monotherapy

Concomitant therapy: Beneficiary will continue to receive intranasal steroid concomitantly

form requires confirmation that intranasal steroid use will continue

Continuation Therapy

Covered for continuation when ALL of the following are met

Attestation of benefit: Prescriber attests beneficiary is receiving continued clinical benefit from baseline supported by medical records

If yes, medical records must be attached per form

Prescriber signature and date required on form

Prescriber signature is mandatory on continuation section

The prior authorization form effectively excludes requests that do not meet the form’s basic eligibility items. Specifically, the form implies non‑coverage when the beneficiary is 18 years of age, when the beneficiary’s weight is outside the 30–150 kg range, or when a diagnosis of nasal polyps is not documented on the form.

The form requires documentation that the beneficiary has previously undergone and failed a course of intranasal steroid monotherapy before initiating omalizumab; the checkbox asking “Has the beneficiary tried and failed monotherapy with nasal steroids?” must be completed. The form also requires confirmation that the beneficiary will continue to receive an intranasal steroid concomitantly (the checkbox “Will the beneficiary continue to receive intranasal steroid concomitantly?”), and absence of these documented items on the form may jeopardize approval.

Coding, Age, Weight, and IgE Parameters

Affected codes indicatedmixed

affected codes

Placeholder in document; specific CPT/HCPCS/NDC codes not listed on form

Age — Minimum age requirement

Minimum ageBeneficiary must be 18 years of age or older

If under 18Form indicates beneficiary under 18 is not eligible

Age question location'Nasal Polyps: New Therapy' form question 1 asks if beneficiary is 18 years or older

Weight — Allowed weight range (30–150 kg)

Allowed weight rangeBeneficiary must weigh between 30 kg (66 lbs) and 150 kg (330 lbs)

Weight documentationForm includes a field to record beneficiary's weight if 'No' is selected

Weight question location'Nasal Polyps: New Therapy' form question 2 asks about weight range

IgE level — Threshold asked on form (> 30 IU/ml)

IgE threshold asked on formForm asks whether beneficiary has an IgE level above 30 IU/ml (Yes/No)

Record level if availableForm includes a line: 'Please list level:' to record the numerical IgE value

IgE question location'Nasal Polyps: New Therapy' form question 3 addresses IgE level

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required. Submit the completed prior authorization form including beneficiary and prescriber details, beneficiary age and weight, serum IgE level, diagnosis of nasal polyps, prior therapy information (trial and failure of intranasal steroid monotherapy), and whether intranasal steroid will be continued concomitantly.

Include beneficiary age and weight (must be 18 years or older and weigh between 30–150 kg).
Include serum IgE level (must be > 30 IU/mL) and documentation of nasal polyps diagnosis.
Document prior trial and failure of intranasal steroid monotherapy and indicate if intranasal steroid will be continued.

Denial Risk

Denial Risk — Eligibility Failures

Potential denial risk if the patient does not meet key eligibility criteria. Review these before submission to avoid delays.

Age < 18 years.
Weight < 30 kg or > 150 kg.
No documented diagnosis of nasal polyps.
Serum IgE ≤ 30 IU/mL.
No documentation of trial and failure of intranasal steroid monotherapy.

Documentation Required

Documentation Required for Continuation

For continuation of therapy, the prescriber must attest that the beneficiary is receiving continued clinical benefit compared with baseline and must attach supporting medical records. Prescriber signature and date are required on the continuation form.

Attach medical records demonstrating continued clinical benefit from baseline.
Prescriber must sign and date the continuation attestation (signature mandatory).
Include documentation of ongoing concomitant intranasal steroid use if applicable.