Background

Dupixent is an interleukin–4 receptor alpha antagonist indicated for the treatment of patients aged 6 months and older with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Dupixent is also approved as add-on maintenance treatment in patients with moderate to severe asthma aged 6 years and older with an eosinophilic phenotype or with oral corticosteroid dependent asthma. Dupixent later gained an indication as an add-on maintenance treatment in adult and pediatric patients 12 years of age and older with inadequately controlled chronic rhinosinusitis with nasal polyposis and an indication for the treatment of eosinophilic esophagitis in adults and pediatric patients aged 1 year and older, weighing at least 15 kg as well as an indication for the treatment of prurigo nodularis. Dupixent’s most recent indications include chronic obstructive pulmonary disease treatment of adult and pediatric patients 12 years of age and older with chronic spontaneous urticaria (CSU) and treatment of adult patients with bullous pemphigoid. Please see the package insert for details on dosing.

Atopic Dermatitis

There are various treatment options for atopic dermatitis, including first line agents such as topical corticosteroids (many of which are in generic form) and topical immunomodulatory agents such as generic tacrolimus and generic pimecrolimus. For those that are refractory to topical therapies, systemic immunomodulatory agents are an option for therapy. Dupixent has not yet been integrated into the American Academy of Dermatology guidelines at the time of this publication.

Asthma

Asthma is a respiratory disorder characterized by increased responsiveness of the trachea and bronchi to various stimuli resulting in the narrowing of the airways, along with mucous secretion. Symptoms vary in severity and intensity and include wheezing, cough and dyspnea. Attacks can be triggered by exercise, allergens, irritants, and viral infections. Based on symptoms, the four levels of asthma severity are:

• Mild intermittent (comes and goes)—you have episodes of asthma symptoms twice a week or less, and you are bothered by symptoms at night twice a month or less; between episodes, however, you have no symptoms and your lung function is normal.
• Mild persistent asthma—you have asthma symptoms more than twice a week, but no more than once in a single day. You are bothered by symptoms at night more than twice a month. You may have asthma attacks that affect your activity.
• Moderate persistent asthma—you have asthma symptoms every day, and you are bothered by nighttime symptoms more than once a week. Asthma attacks may affect your activity.
• Severe persistent asthma—you have symptoms throughout the day on most days, and you are bothered by nighttime symptoms often. In severe asthma, your physical activity is likely to be limited. Treatment of asthma is based on a step-up and step-down approach based on asthma severity and symptoms. Medications include short acting beta agonists for fast relief. Long term treatment centers around the use of ICSs and possible addition of medications such as long-acting beta agonists, LTRAs, inhaled long-acting muscarinic antagonists, or theophylline. In the past few years, biologic products have been approved for the treatment of asthma, including Xolair, Nucala, Fasenra, and Cinqair for those that are not controlled on traditional agents. Guidelines have not been updated to include Dupixent.

Chronic Rhinosinusitis with Nasal Polyposis

Chronic rhinosinusitis is an inflammatory condition involving the nasal sinuses and the lining of the nasal passages. Chronic rhinosinusitis often involves nasal drainage, nasal obstruction, facial pain and/or pressure and decreased sense of smell. Chronic rhinosinusitis with nasal polyposis is characterized by the presence of bilateral nasal polyps in the middle meatus. As imagined, these polyps lead to worsening nasal congestion, pressure, drainage, etc. Treatments for chronic rhinosinusitis with nasal polyposis include various treatment modalities including, but not limited to, intranasal saline, intranasal steroids, oral steroids, surgery, non-sedating antihistamines, antileukotriene agents, and for those who have failed these more traditional therapies, Dupixent (which is the first monoclonal antibody approved for this condition).

Eosinophilic Esophagitis

Eosinophilic esophagitis is a chronic allergic/immune condition of the esophagus. It is characterized by an increased number of eosinophils in the esophagus, which are normally not present at all. It often presents as dysphagia, food impaction, chest pain that may not respond to antacids, gastroesophageal reflux disease-like symptoms, or upper abdominal pain in adults and feeding dysfunction, vomiting, abdominal pain, dysphagia, or food impaction in children. Effective nonpharmacologic therapy for the treatment of this condition consists of dietary modifications. Elimination and elemental diets are the two recommended dietary modifications in which known or suspected allergens be removed from the diet in elimination or an individual is limited to an amino acid formula as the main source of nutrition in elemental. Despite the recent approval of agents specifically for this condition, off label use of proton pump inhibitors has remained as one of the first line treatment options.

Prurigo Nodularis

Prurigo nodularis (PN) is an uncommon skin disorder that is characterized by symmetrically distributed multiple, firm, pruritic nodules. The exact pathogenesis of the disorder is unclear. PN typically presents with firm, dome-shaped nodules that range in size and can be flesh-colored, erythematous, brown, or black. They often range in number from just a few to hundreds of lesions. Another core symptom of PN is pruritus lasting greater than or equal to 6 weeks that has led to signs of repeated scratching, picking, or rubbing. PN can occur all over the body, but the face, palms of the hand, soles of the feet, and genitalia are rarely affected. PN has a profound impact on a patient’s quality of life, often due to sleep deprivation, depression, and anxiety. Several medical conditions are associated with PN such as atopic dermatitis, chronic kidney disease, diabetes, heart failure, hepatitis B or C virus, HIV, and non-Hodgkin lymphoma. When diagnosing PN, it is recommended for clinicians to do a full review of systems, especially in patients who do not have a history of a pruritic skin condition, to assess if there is a systemic disease or malignancy possibly causing PN. Treatment goals for PN include reducing pruritus, interrupting the itch-scratch cycle, and completely healing PN lesions. Several recommended therapies are off-label treatments that include gentle skin care, antipruritic emollients, topical corticosteroids, topical calcineurin inhibitors, topical capsaicin, neuromodulators, antidepressants, phototherapy, and immunosuppressants. Dupixent is the first therapeutic agent to be FDA approved for PN.

Chronic Obstructive Pulmonary Disease

COPD is a chronic lung condition that is characterized by respiratory symptoms stemming from abnormalities in the airways, which often cause bronchitis and bronchiolitis, and/or from the alveoli, which often causes emphysema. Common symptoms of COPD include dyspnea, wheezing, chest tightness, and a cough that may or may not present with sputum production. Diagnosis of COPD is confirmed with spirometry demonstrating that airflow limitation is either irreversible or only partially reversible as defined by a post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio less than 0.7. Treatment regimens are typically based on an assessment of symptoms and exacerbation history. Long-acting bronchodilators, including longacting beta agonists (LABAs), long-acting muscarinic antagonists (LAMAs), and combination products containing both of these classes are the mainstay of maintenance treatment for this condition. Inhaled corticosteroids in combination with a LABA and LAMA are considered for those who have a blood eosinophil level ≥ 300 cells/microliter. Daliresp®‡ (roflumilast), an oral PDE4 inhibitor, systemic corticosteroids, antibiotics, and mucolytics may also be considered in select patients. Dupixent is the first biologic approved to treat COPD.

Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is defined by the presence of itchy hives that last for at least 6 weeks, with or without angioedema, and have no apparent external trigger. Typical treatments for CSU include antihistamines, leukotriene modifiers, and immunomodulatory agents.

Bullous Pemphigoid

Bullous pemphigoid is a rare autoimmune skin blistering disease. This condition presents with painful blisters that occur in the mouth and/or other areas of the skin or body. Typical treatments for bullous pemphigoid include corticosteroids (topical or oral).

 

Policy (Criteria)

Coverage of these drugs is provided when the criteria below is met and for non-preferred products there has been a trial and failure of preferred therapy (if applicable).

Dupilumab may be considered MEDICALLY NECESSARY for the following condition(s):

Atopic dermatitis

1. Diagnosis of moderate to severe atopic dermatitis
2. One of the following:

• Involvement of at least 10% body surface area (BSA)
• SCORing Atopic Dermatitis (SCORAD) index value of at least 25

3. Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication (e.g., safety concerns, not indicated for member's age/weight), or intolerance to at least ONE of the following:

• Medium or higher potency topical corticosteroid
• Generic topical calcineurin inhibitor (e.g., tacrolimus ointment)
• Eucrisa (crisaborole) ointment
• Opzelura (ruxolitinib) cream
• Zoryve (roflumilast) 0.15% cream

4.  Member meets FDA approved age requirement
5. Prescribed by or in consultation with one of the following:

• Dermatologist
• Allergist/Immunologist

Authorization duration: 6 months

Continuation therapy

Demonstrates a positive clinical response to therapy as evidenced by at least ONE of the following:

• Reduction in body surface area involvement from baseline
• Reduction in SCORing Atopic Dermatitis (SCORAD) index value from baseline

Authorization duration: 12 months

Eosinophilic Asthma

1. Diagnosis of moderate to severe asthma
2. Asthma is an eosinophilic phenotype as defined by a baseline (pre-treatment) peripheral blood eosinophil level greater than or equal to 150 cells per microliter
3. One of the following:
   1. Member has had at least two or more asthma exacerbations requiring systemic corticosteroids (e.g., prednisone) within the past 12 months
   2. Prior asthma–related hospitalization within the past 12 months
4. One of the following:
   1. Both of the following:
      1. Member is 6 years of age or older but less than 12 years of age
      2. Member is currently being treated with one of the following unless there is a contraindication or intolerance to these medications:
   2. Both of the following:
      1. Medium–dose inhaled corticosteroid (e.g., greater than 100 – 200 mcg fluticasone propionate equivalent/day)
      2. Additional asthma controller medication (e.g., leukotriene receptor antagonist [LTRA] [e.g., montelukast], long-acting beta-2 agonist [LABA] [e.g., salmeterol], long–acting muscarinic antagonist [LAMA] [e.g., tiotropium]) OR
      3. One medium dosed combination ICS/LABA product (e.g., Advair Diskus [fluticasone propionate 100mcg/ salmeterol 50mcg], Symbicort [budesonide 80mcg/ formoterol 4.5mcg] Breo Ellipta [fluticasone furoate 50 mcg/ vilanterol 25 mcg])
   3. Both of the following:
      1. Member is 12 years of age or older
      2. Member is currently being treated with one of the following unless there is a contraindication or intolerance to these medications:
   4. Both of the following:
      1. High-dose inhaled corticosteroid (ICS) (e.g., greater than 500 mcg fluticasone propionate equivalent/day)
      2. Additional asthma controller medication (e.g., leukotriene receptor antagonist [LTRA] [e.g., montelukast], long-acting beta-2 agonist [LABA] [e.g., salmeterol], long–acting muscarinic antagonist [LAMA] [e.g., tiotropium])
      3. OR One maximally-dosed combination ICS/LABA product (e.g., Advair [fluticasone propionate 500mcg/ salmeterol 50mcg], Symbicort [budesonide 160mcg/ formoterol 4.5mcg], Breo Ellipta [fluticasone 200mcg/ vilanterol 25mcg])
5. Prescribed by or in consultation with one of the following:

• Pulmonologist
• Allergist/Immunologist

Authorization duration: 6 months

Continuation therapy for Eosinophilic Asthma must meet the following criteria:

1. Demonstrates a positive clinical response to therapy (e.g., reduction in exacerbations, improvement in forced expiratory volume in 1 second [FEV1], decreased use of rescue medications)
2. Member continues to be treated with an inhaled corticosteroid (ICS) (e.g., fluticasone, budesonide) with or without additional asthma controller medication (e.g., leukotriene receptor antagonist [LTRA] [e.g., montelukast], long–acting beta–2 agonist [LABA] [e.g., salmeterol], long-acting muscarinic antagonist [LAMA] [e.g., tiotropium]) unless there is a contraindication or intolerance to these medications
3. Prescribed by or in consultation with one of the following:

• Pulmonologist
• Allergist/Immunologist

Authorization duration: 12 months

Oral Corticosteroid Dependent Asthma

1. Diagnosis of moderate to severe asthma
2. Member is currently dependent on oral corticosteroids for the treatment of asthma
3. One of the following:
   1. Both of the following:
      1. Member is 6 years of age or older but less than 12 years of age
      2. Member is currently being treated with one of the following unless there is a contraindication or intolerance to these medications: Medium-dose inhaled corticosteroid (e.g., greater than 100 – 200 mcg fluticasone propionate equivalent/day) AND Additional asthma controller medication (e.g., leukotriene receptor antagonist [LTRA] [e.g., montelukast], long-acting beta-2 agonist [LABA] [e.g., salmeterol], long-acting muscarinic antagonist [LAMA] [e.g., tiotropium]) OR One medium dosed combination ICS/LABA product (e.g., Advair Diskus [fluticasone propionate 100mcg/ salmeterol 50mcg], Symbicort [budesonide 80mcg/ formoterol 4.5mcg] Breo Ellipta [fluticasone furoate 50 mcg/ vilanterol 25 mcg])
   2. Both of the following:
      1. Member is 12 years of age or older
      2. Member is currently being treated with one of the following unless there is a contraindication or intolerance to these medications: High-dose inhaled corticosteroid (ICS) (e.g., greater than 500 mcg fluticasone propionate equivalent/day) AND Additional asthma controller medication (e.g., leukotriene receptor antagonist [LTRA] [e.g., montelukast], long-acting beta-2 agonist [LABA] [e.g., salmeterol], long-acting muscarinic antagonist [LAMA] [e.g., tiotropium]) OR One maximally-dosed combination ICS/LABA product (e.g., Advair [fluticasone propionate 500mcg/ salmeterol 50mcg], Symbicort [budesonide 160mcg/ formoterol 4.5mcg], Breo Ellipta [fluticasone 200mcg/ vilanterol 25mcg])
4. Prescribed by or in consultation with one of the following:

• Pulmonologist
• Allergist/Immunologist

Authorization duration: 6 months

Continuation therapy for Oral Corticosteroid Dependent Asthma must meet the following criteria:

1. Demonstrates a positive clinical response to therapy (e.g., reduction in exacerbations, improvement in forced expiratory volume in 1 second [FEV1], reduction in oral corticosteroid dose)
2. Member continues to be treated with an inhaled corticosteroid (ICS) (e.g., fluticasone, budesonide) with or without additional asthma controller medication (e.g., leukotriene receptor antagonist [LTRA] [e.g., montelukast], long-acting beta-2 agonist [LABA] [e.g., salmeterol], long-acting muscarinic antagonist [LAMA] [e.g., tiotropium]) unless there is a contraindication or intolerance to these medications
3. Prescribed by or in consultation with one of the following:

• Pulmonologist
• Allergist/Immunologist

Authorization duration: 12 months

Chronic rhinosinusitis with nasal polyposis (CRSwNP)

1. Diagnosis of chronic rhinosinusitis with nasal polyposis (CRSwNP)
2. Unless contraindicated, the member has had an inadequate response to 2 months of treatment with an intranasal corticosteroid (e.g., fluticasone, mometasone)
3. Used in combination with another agent for CRSwNP
4. Prescribed by or in consultation with one of the following:

• Allergist/Immunologist
• Otolaryngologist
• Pulmonologist

5. Member meets FDA approved age requirement

Authorization duration: 12 months

Continuation therapy for CRSwNP must meet the following criteria:

1. Demonstrates a positive clinical response to therapy (e.g., reduction in nasal polyps score [NPS; 0-8 scale], improvement in nasal congestion/obstruction score [NC; 0-3 scale])
2. Used in combination with another agent for CRSwNP
3. Prescribed by or in consultation with one of the following:

• Allergist/Immunologist
• Otolaryngologist
• Pulmonologist

Authorization duration: 12 months

Eosinophilic Esophagitis (EoE)

1. Diagnosis of eosinophilic esophagitis (EoE)
2. Member has symptoms of esophageal dysfunction (e.g., dysphagia, food impaction, gastroesophageal reflux disease [GERD]/heartburn symptoms, chest pain, abdominal pain)
3. Member has at least 15 intraepithelial eosinophils per high power field (HPF)
4. Other causes of esophageal eosinophilia have been excluded
5. Both of the following:

• Member meets FDA approved age requirement
• Member weighs at least 15 kg

6. Trial and failure, contraindication, or intolerance to at least an 8-week trial of one of the following:

• Proton pump inhibitors (e.g., pantoprazole, omeprazole
• Topical (esophageal) corticosteroids (e.g., budesonide, fluticasone)

7. Prescribed by or in consultation with one of the following:

• Gastroenterologist
• Allergist/Immunologist

Authorization duration: 12 months

Continuation therapy for EoE must meet the following criteria:

Demonstrates a positive clinical response to therapy as evidenced by improvement of at least one of the following from baseline:

• Symptoms (e.g., dysphagia, food impaction, heartburn, chest pain)
• Histologic measures (e.g., esophageal intraepithelial eosinophil count)
• Endoscopic measures (e.g., edema, furrows, exudates, rings, strictures)

Authorization duration: 12 months

Prurigo Nodularis (PN)

1. Diagnosis of prurigo nodularis (PN)
2. Member has at least 20 nodular lesions
3. Trial and failure, contraindication, or intolerance to one medium or higher potency topical corticosteroid
4. Prescribed by or in consultation with one of the following:

• Allergist/Immunologist
• Dermatologist

Authorization duration: 6 months

Continuation therapy for Prurigo Nodularis (PN) must meet the following criteria:

Demonstrates a positive clinical response to therapy as evidenced by at least ONE of the following:

• Reduction in the number of nodular lesions from baseline
• Improvement in symptoms (e.g., pruritus, inflammation) from baseline

Authorization duration: 12 months

Chronic obstructive pulmonary disease (COPD)

1. Diagnosis of chronic obstructive pulmonary disease (COPD )
2. Presence of Type 2 inflammation evidenced by blood eosinophils greater than or equal to 300 cells per microliter at baseline
3. Member is receiving one of the following therapies at maximally tolerated doses:

• Triple therapy (i.e., an inhaled corticosteroid (ICS), a long-acting muscarinic antagonist (LAMA) and a long-acting beta agonist (LABA)
• If ICS are contraindicated, a LAMA and a LABA

4. Member has had one of the following within the past 12 months:
   1. At least two exacerbations where systemic corticosteroids [intramuscular, intravenous, or oral (e.g., prednisone)] were required at least once
   2. COPD-related hospitalization
5. Member experiences dyspnea during everyday activities (e.g., needs to stop for breath when walking on level ground)
6. Member must have post-bronchodilator forced expiratory volume [FEV1] / forced vital capacity [FVC] ratio less than 0.70

Authorization duration: 6 months

Continuation therapy for COPD must meet the following criteria:

1. Member demonstrates a positive clinical response to therapy (e.g., improved lung function, a reduction in COPD exacerbations)
2. Member continues to receive one of the following therapies at an optimized dose:

• Triple therapy (i.e., an inhaled corticosteroid (ICS), a long-acting muscarinic antagonist (LAMA) and a long-acting beta agonist (LABA)
• If ICS are contraindicated, a LAMA and a LABA

Authorization duration: 12 months

Chronic Spontaneous Urticaria (CSU)

1. Diagnosis of chronic spontaneous urticaria
2. Member meets FDA approved age requirement
3. Both of the following:
   1. Persistent symptoms (itching and hives) for at least 6 consecutive weeks despite concurrent use of a second generation H1 antihistamine (e.g., cetirizine, fexofenadine), unless there is a contraindication or intolerance to H1 antihistamines
   2. Minimum 2-week trial of up-dosing (e.g., up to 4x dose) of the second generation H1 antihistamine, unless there is a contraindication or intolerance to H1 antihistamines
4. Will be used concurrently with a second generation H1 antihistamine, unless there is a contraindication or intolerance to H1 antihistamines
5. Prescribed by or in consultation with a dermatologist or allergist/immunologist

Authorization duration: 6 months

Continuation therapy for Chronic Spontaneous Urticaria (CSU) must meet the following criteria:

Demonstrates positive clinical response to therapy as evidenced by a reduction from baseline in itching severity or the number of hives

Authorization duration: 12 months

Bullous Pemphigoid (BP)

Initial therapy

1. Diagnosis of bullous pemphigoid (BP) as confirmed by skin biopsy or serology
2. Will be used in combination with a tapering course of oral corticosteroids (e.g., prednisone) until disease control has occurred
3. Prescribed by or in consultation with an allergist/immunologist or a dermatologist

Authorization duration: 6 months

Continuation therapy for Bullous Pemphigoid (BP) must meet the following criteria:

Demonstrates positive clinical response to therapy (e.g., decreased pruritus severity from baseline, no new lesions or worsening of old lesions).

Authorization duration: 12 months

References

1. Dupixent [package insert]. Regeneron Pharmaceuticals, Inc. Tarrytown, New York. Updated June 2025.
2. Dupixent Drug Evaluation. Express Scripts. Updated October 2018.
3. Dupixent Prior Authorization Policy. Express Scripts. Updated October 2022.
4. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis Section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71(2): 327-349.
5. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis. Section 2: management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71(1):116-132.
6. Initiative for Asthma. Global strategy for asthma management and prevention. Updated February 2018. Available at: http://www.ginasthma.org. Accessed on: October 22, 2018.
7. Castro M, Corren J, Pavord ID, et al. Dupilumab efficacy and safety in moderate-to-severe uncontrolled asthma. N Engl J Med. 2018;378(26);2486-2496.
8. Rabe KF, Nair P, Brusselle G, et al. Efficacy and safety of dupilumab in glucocorticoiddependent severe asthma. N Engl J Med. 2018;378(26):2475-2485.
9. Wenzel S, Castro M, Corren J, et al. Dupilumab efficacy and safety in adults with uncontrolled persistent asthma despite use of medium-to-high-dose inhaled corticosteroids plus a long-acting β2 agonist: a randomised double-blind placebo-controlled pivotal phase 2b dose-ranging trial. Lancet. 2016;388(10039):31-44.
10. Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014;43:343-373.
11. Chronic rhinosinusitis: Management. UpToDate. Accessed October 2019.
12. Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis. UpToDate. Accessed October 2019.
13. Garrido Colmenero C, Blasco Morente G, Tercedor Sánchez J. Oral Cyclosporine Weekend Therapy: A New Maintenance Therapeutic Option in Patients with Severe Atopic Dermatitis. Pediatr Dermatol 2015; 32:551.
14. Schmitt J, Schmitt N, Meurer M. Cyclosporin in the treatment of patients with atopic eczema -a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2007; 21:606.
15. Sidbury R, Davis DM, Cohen DE, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol 2014; 71:327.
16. Shea B, Swinden MV, Ghogomu ET, et al. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. J Rheumatol 2014; 41:1049.
17. Dvorakova V, O'Regan GM, Irvine AD. Methotrexate for Severe Childhood Atopic Dermatitis: Clinical Experience in a Tertiary Center. Pediatr Dermatol 2017; 34:528.
18. Deo M, Yung A, Hill S, Rademaker M. Methotrexate for treatment of atopic dermatitis in children and adolescents. Int J Dermatol 2014; 53:1037.
19. Rahman SI, Siegfried E, Flanagan KH, Armbrecht ES. The methotrexate polyglutamate assay supports the efficacy of methotrexate for severe inflammatory skin disease in children. J Am Acad Dermatol 2014; 70:252.
20. Roberts H, Orchard D. Methotrexate is a safe and effective treatment for paediatric discoid (nummular) eczema: a case series of 25 children. Australas J Dermatol 2010; 51:128.
21. Anderson K, Putterman E, Rogers RS, et al. Treatment of severe pediatric atopic dermatitis with methotrexate: A retrospective review. Pediatr Dermatol 2019; 36:298.
22. Purvis D, Lee M, Agnew K, et al. Long-term effect of methotrexate for childhood atopic dermatitis. J Paediatr Child Health 2019; 55:1487.
23. El-Khalawany MA, Hassan H, Shaaban D, et al. Methotrexate versus cyclosporine in the treatment of severe atopic dermatitis in children: a multicenter experience from Egypt. Eur J Pediatr 2013; 172:351.
24. Tsakok T, Flohr C. Methotrexate vs. ciclosporin in the treatment of severe atopic dermatitis in children: a critical appraisal. Br J Dermatol 2014; 170:496.
25. Taylor K, Swan DJ, Affleck A, et al. Treatment of moderate-to-severe atopic eczema in adults within the U.K.: results of a national survey of dermatologists. Br J Dermatol 2017; 176:1617.
26. Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE). UpToDate. Accessed July 2022.
27. Eosinophilic Esophagitis. American Academy of Allergy Asthma and Immunology. Updated May 2022. Available at: https://www.aaaai.org/Conditions-Treatments/relatedconditions/eosinophilic-esophagitis. Accessed on: July 25, 2022.
28. Prurigo nodularis. UpToDate. Accessed February 2023.
29. Elmariah S, Kim B, Berger T, et al. Practical approaches for diagnosis and management of prurigo nodularis: United States expert panel consensus. J Am Acad Dermatol. 2021;84(3):747-760.

Coding Section

Code	Number	Description
ICD-10	L20	Atopic dermatitis
	L20.0	Besnier’s prurigo
	L20.81	Atopic neurodermatitis
	L20.82	Flexural eczema
	L20.84	Intrinsic (allergic) eczema
	L20.8	Other atopic dermatitis
	L20.89	Other atopic dermatitis
	L20.9	Atopic dermatitis, unspecified
	L28.1	Prurigo nodularis
	L50.1	Idiopathic urticaria
	L50.8	Other urticaria
	L50.9	Urticaria, unspecified
	L12.0	Bullous Pemphigoid
	L12.8	Other Pemphigoid
	L12.9	Pemphigoid, unspecified
	L13.9	Bullous disorders, unspecified
	J45.4	Moderate persistent asthma
	J45.40	asthma Moderate persistent asthma, uncomplicated
	J45.41	Moderate persistent asthma with (acute) exacerbation
	J45.5	Severe persistent asthma
	J45.50	Severe persistent asthma, uncomplicated
	J45.51	Severe persistent asthma with (acute) exacerbation
	J45.9	Other and unspecified asthma
	J45.90	Unspecified asthma
	J45.901	Unspecified asthma with (acute) exacerbation
	J82.83	Eosinophilic asthma
	J33	Nasal polyp
	J33.0	Polyp of the nasal cavity
	J33.1	Polypoid sinus degeneration
	J33.8	Other polyp of sinus
	J33.9	Nasal polyp, unspecified
	J44	Other chronic obstructive pulmonary disease
	J44.0	Chronic obstructive pulmonary disease with (acute) lower respiratory infection
	J44.1	Chronic obstructive pulmonary disease with (acute) exacerbation
	J44.9	Chronic obstructive pulmonary disease, unspecified
	J40	Bronchitis, not specified as acute or chronic
	J41	Simple and mucopurulent chronic bronchitis
	J41.0	Simple chronic bronchitis
	J41.1	Mucopurulent chronic bronchitis
	J41.8	Mixed simple and mucopurulent chronic bronchitis
	J42	Unspecified chronic bronchitis
	J43	Emphysema
	K20.0	Eosinophilic esophagitis
HCPCS	J3590	Unclassified Biologics

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2025 Forward

11/01/2025

New Policy