CurrentUnitedHealthcarePolicy N/A

Dupixent (dupilumab) prior authorization for chronic rhinosinusitis with nasal polyposis (CRSwNP)

Authorization form governing initial and continuation coverage requirements for Dupixent (dupilumab) for beneficiaries with chronic rhinosinusitis with nasal polyposis; completed by prescribing provider for UnitedHealthcare beneficiaries.

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) prior authorization for chronic rhinosinusitis with nasal polyposis (CRSwNP)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete prior authorization verifying beneficiary is ≥18, has CRSwNP, failed intranasal steroid monotherapy, documents prior systemic corticosteroid history or contraindication, and provide medical records showing clinical benefit for continuation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+min age

past 2 yearssteroid window

documented benefit requiredcontinuation need

concomitant useintranasal steroid

Coverage criteria for Dupixent (dupilumab)

Initial Therapy

Covered when ALL of the following are met

Initial Authorization Criteria: Beneficiary is 18 years of age or older

Captured by question 1 on the form

Initial Authorization Criteria: Beneficiary has a diagnosis of chronic rhinosinusitis with nasal polyposis (CRSwNP)

Captured by diagnosis question on the form

Initial Authorization Criteria: Beneficiary failed monotherapy with intranasal (nasal) corticosteroids

Captured by failure of nasal steroid monotherapy question on the form

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) prior authorization for chronic rhinosinusitis with nasal polyposis (CRSwNP)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Continuation Therapy

Continuation of therapy covered when ALL of the following are met

Continuation Criteria: While on Dupixent, beneficiary has continued clinical benefit from baseline supported by medical records

Question 7 on continuation form

Continuation Criteria: Provide medical records documenting the beneficiary's current nasal polyps status and response to Dupixent treatment

Continuation form requests medical records documenting current Nasal Polyps status and response

Continuation Criteria: Prescriber signature and date are provided on the continuation form

Prescriber signature is mandatory on the form

The form relies on completed responses and supporting documentation to establish medical necessity. If required answers or records are omitted — for example, the beneficiary’s age, a documented diagnosis of CRSwNP, evidence of prior failure of intranasal corticosteroid monotherapy, documentation of systemic corticosteroid use (or contraindication) in the past 2 years, or, for continuation requests, medical records showing continued clinical benefit — the request is not supported and may be denied. The continuation section explicitly requests medical records and a prescriber signature, and absence of these items increases denial risk.

Initial therapy requirements

Initial Therapy

Initial Dupixent authorization requirements

Initial Dupixent: Beneficiary is 18 years of age or older

Form question 1

Initial Dupixent: Diagnosis of chronic rhinosinusitis with nasal polyposis (CRSwNP)

Form diagnosis question

Initial Dupixent: Failure of monotherapy with intranasal (nasal) corticosteroids

Form asks whether beneficiary failed nasal steroid monotherapy

Initial Dupixent: Prior treatment for nasal polyps with systemic corticosteroids in the past 2 years OR documented contraindication to systemic corticosteroids

Form asks about systemic corticosteroid use in past 2 years or contraindications and requests listing

Initial Dupixent: Plan to continue intranasal steroid with Dupixent

Form asks if intranasal steroid will be continued in conjunction with Dupixent

Criteria to continue therapy

Continuation of Therapy

Requirements to continue Dupixent

Continuation: Beneficiary demonstrates continued clinical benefit from baseline while on Dupixent, as answered on the form

Question 7 requires Yes and documentation

Continuation: Provide medical records documenting current nasal polyps status and the beneficiary's response to Dupixent treatment

Continuation form explicitly requests these medical records

Continuation: Prescriber signature and date are included on the continuation request

Prescriber signature is mandatory

Provider actions, documentation, and step requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for Dupixent (dupilumab) for chronic rhinosinusitis with nasal polyposis (CRSwNP). Requests must confirm the beneficiary is 18 years or older, has a documented CRSwNP diagnosis, and has failed monotherapy with intranasal corticosteroids prior to approval.

Required: beneficiary age (DOB) and confirmation ≥18
Required: diagnosis of CRSwNP documented in medical record
Required: documentation of prior failure of intranasal corticosteroid monotherapy
Required: documentation of systemic corticosteroid use for nasal polyps in past 2 years OR documented contraindication to systemic corticosteroids (for initial authorization)
Required for continuation: medical records documenting current nasal polyps status and clinical response to Dupixent from baseline

Documentation Required

Required Form Fields & Documentation

Provide the following completed fields on the request form and attach supporting documentation (medical records progress notes, imaging, procedure notes, medication history):

Beneficiary last name, first name, Beneficiary ID #, Date of Birth, Gender
Prescribing provider NPI and requester contact name and phone number
Drug name, strength, quantity per 30 days, and requested length of therapy (select 30/60/90/120/180/365 days)
Completed clinical questions: confirmation beneficiary ≥18, CRSwNP diagnosis, prior intranasal steroid monotherapy failure, prior systemic corticosteroid use in past 2 years or contraindication, plan to continue intranasal steroid with Dupixent
Attach: medical records showing baseline status and ongoing clinical benefit (for continuation), documentation of prior therapies and responses

Denial Risk

Denial Triggers

Requests missing the following will be denied: age <18 or failure to document age ≥18; no documented CRSwNP diagnosis; no documentation of prior failure of intranasal corticosteroid monotherapy; absence of documentation of prior systemic corticosteroid therapy in the past 2 years when required or lack of documented contraindication; incomplete form fields (beneficiary demographics, prescriber NPI/contact, drug details) or missing medical records supporting current nasal polyps status and response to therapy.

No documentation beneficiary is ≥18 years old
No documented diagnosis of chronic rhinosinusitis with nasal polyposis (CRSwNP)
No documentation of prior intranasal steroid monotherapy failure
No documentation of systemic corticosteroid treatment for nasal polyps in past 2 years or a documented contraindication when applicable
Incomplete form fields (missing beneficiary demographics, prescriber NPI/contact, drug name/strength/quantity/length)
Missing medical records documenting nasal polyps status and clinical response (for continuation requests)

Step	Requirement	Failure criteria
1	Documented failure of intranasal corticosteroid monotherapy is required prior to initiation of Dupixent (dupilumab).	Provider must indicate prior failure of monotherapy with nasal (intranasal) steroids on the authorization form (question: 'Has the beneficiary failed monotherapy with nasal steroids?').

Quantity and duration limits

Dupixent (dupilumab) — Quantity Per 30 Days

Field on request formQuantity Per 30 Days is a user-entered numeric field on the Drug Information section of the form (line 10).

Where providedEntered by prescriber in Drug Information (Drug Name, Strength, Quantity Per 30 Days).

Unit of measurementMonth-based quantity (per 30 days) as captured on the form.

Dupixent (dupilumab) — Length of Therapy

Selectable duration optionsLength of Therapy selectable on the form with options: up to 30, 60, 90, 120, 180, or 365 days.

Where providedPrescriber indicates Length of Therapy (in days) in the Drug Information section (line 11).

Maximum duration365 days is the longest selectable option on the form.

Background

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a persistent inflammatory condition identified on the form as the indication for Dupixent (dupilumab). The authorization captures key elements used to determine appropriateness of therapy: beneficiary age (must be 18 years or older for initial requests), prior treatment history including failure of intranasal corticosteroid monotherapy and prior systemic corticosteroid use within the past 2 years (or documented contraindication), and evidence of clinical benefit on therapy for continuation approvals. The form also asks whether intranasal steroid therapy will be continued concomitantly with Dupixent.

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