CurrentAetnaPolicy N/A

Cinqair (reslizumab) Medication Precertification Request / Coverage Criteria

This document is Aetna's precertification request form and required clinical information for initiating or continuing Cinqair (reslizumab) therapy for members; it governs what providers must submit for authorization review.

Policy Summary

PayerAetna

PolicyCinqair (reslizumab) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrecertification must be requested via Aetna's Cinqair medication precertification form using the listed phone or fax numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

1-866-752-7021Aetna precert phone

1-888-267-3277Aetna precert fax

requiredclinical info

Coverage Criteria for Cinqair (reslizumab)

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Initial Request Criteria: 1) Documented diagnosis of asthma; 2) Medication prescribed by or in consultation with an allergist, immunologist, or pulmonologist; 3) Continued use of maintenance asthma treatments (inhaled corticosteroid plus additional controller) while receiving the requested medication; 4) Baseline blood eosinophil count provided (baseline = before significant oral steroid use); 5) Evidence of uncontrolled asthma demonstrated by ANY of: two or more exacerbations requiring oral or injectable corticosteroids in the past year OR one or more exacerbation resulting in hospitalization or emergency medical care visit in the past year OR poor symptom control within the past year (frequent symptoms or reliever use, activity limitation, or night waking); 6) Prior inadequate control despite high‑dose inhaled corticosteroid plus an additional controller at optimized doses, or dependence on systemic corticosteroids, when applicable; 7) Documentation of prior biologic use or documentation that preferred alternatives (Fasenra, Nucala, Tezspire, Xolair) are ineffective, not tolerated, or contraindicated.

Provider must complete form checkboxes and submit supporting clinical documentation including baseline eosinophil count and exacerbation history.

Continuation Therapy

Covered when ALL of the following are met for continuation therapy:

Continuation Request Criteria: 1) Patient is currently receiving the requested medication (including samples or manufacturer patient assistance program); 2) Documentation that asthma control has improved on the requested medication as demonstrated by a reduction in frequency and/or severity of symptoms and exacerbations OR 3) Documentation that asthma control has improved as demonstrated by a reduction in the daily maintenance oral corticosteroid dose; 4) Submission of clinical documentation demonstrating the improvement.

Continuation/recertification form includes checkboxes to indicate samples/patient assistance and specific measures of improvement; supporting documentation must be provided.

Requests to administer Cinqair (reslizumab) in an outpatient hospital setting must include specific clinical justification on the precertification form. Acceptable reasons include a prior severe infusion adverse event that did not respond to conventional interventions (for example, anaphylaxis, anaphylactoid reaction, myocardial infarction, thromboembolism, or seizures), significant venous access issues requiring interventions available only in the outpatient hospital setting, behavioral or cognitive impairment that jeopardizes infusion safety in the absence of a caregiver, or medical instability (cardiovascular, respiratory, renal, or other) that would limit tolerance of infusion volume/loads or predispose the member to severe adverse events that cannot be safely managed outside the hospital. The form requires providers to check the applicable boxes and provide descriptions of the event, venous access problem, behavioral/impairment concern, or the medical instability to support outpatient hospital administration.

Use of Cinqair without the required clinical documentation is not consistent with Aetna’s coverage criteria and may be deemed not medically necessary. For initial requests, the form requires documentation of an asthma diagnosis, confirmation the medication is prescribed by or in consultation with an allergist/immunologist/pulmonologist (specialist involvement), evidence of continued maintenance asthma therapy (inhaled corticosteroid plus additional controller), and a baseline blood eosinophil count (measured before substantial oral steroid use). Initial requests must also document uncontrolled asthma (for example, ≥2 exacerbations requiring oral/injectable corticosteroids in the past year, ≥1 exacerbation resulting in hospitalization/ED visit in the past year, or poor symptom control) and prior treatment history or reasons alternative biologics are ineffective/intolerant/contraindicated. For continuation requests, the form requires evidence the patient is currently receiving the medication and clinical documentation showing improved asthma control (reduced symptoms/exacerbations) or reduced maintenance oral corticosteroid dose. Failure to provide these elements risks denial.

Coding and Billing

Administration/CPT codes (provider-entered)CPT

Administration code(s) (CPT)

Place on form where provider lists applicable CPT administration codes

ICD-10 codes (provider-entered)ICD-10

Primary ICD Code	Primary diagnosis ICD code (provider-entered)
Secondary ICD Code	Secondary diagnosis ICD code (provider-entered)
Other ICD Code	Additional diagnosis ICD code (provider-entered)

inv-07: Asthma exacerbation counts

Exacerbation threshold>= 2 exacerbations requiring oral or injectable corticosteroids in the past 12 months OR >= 1 exacerbation resulting in hospitalization or emergency medical care visit in the past 12 months.

Documentation sourceProvider must indicate exacerbation counts on the initial-request clinical information section of the precertification form.

TimeframePast year (12 months).

Provider Actions and Submission Requirements

Prior Authorization

Precertification submission

Precertification for Cinqair (reslizumab) must be requested using Aetna's Cinqair medication precertification form. Include complete clinical information (see required documentation) or the request may be delayed or denied. Use Aetna Precertification Notification: Phone: 1-866-752-7021 (TTY: 711); FAX: 1-888-267-3277. For Medicare Advantage Part B use the Medicare request form.

Form: Aetna Cinqair (reslizumab) Medication Precertification Request (all fields must be completed and legible)
Aetna Precertification Notification Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277
For Medicare Advantage Part B: Use Medicare request form

Step Therapy

Alternatives and step considerations

List preferred alternative asthma biologic agents that have been ineffective, not tolerated, or are contraindicated. Document prior exposure and reasons for discontinuation or failure.

Fasenra (benralizumab)
Nucala (mepolizumab)
Tezspire (tezepelumab)
Xolair (omalizumab)

Documentation Required

Required documentation

Provide complete documentation with every precertification request. Missing or incomplete clinical information may result in denial or delay of coverage.

Completed patient demographics (name, DOB, contact, weight, height, allergies)
Prescriber information (name, specialty, NPI, state license, phone, fax)
Dispensing provider / facility information and setting (outpatient hospital? yes/no)
Product details: drug name, dose, frequency, indication, primary and secondary ICD codes
Clinical data: documented diagnosis of asthma, baseline blood eosinophil count (cells/µL) for initial requests
Asthma control history: exacerbations (oral/injectable corticosteroid courses, ED visits, hospitalizations) in past year
Prior therapies: documentation of inadequate control on high‑dose inhaled corticosteroid plus an additional controller and any prior biologics and reasons for failure/intolerance
For continuation requests: evidence of improved asthma control and/or reduction in maintenance oral corticosteroid dose; note if receiving samples or manufacturer's assistance

Denial Risk

Incomplete clinical documentation risks denial

Incomplete clinical documentation or failure to provide required fields (diagnosis, labs, prior therapy details, prescriber credentials) risks denial. Ensure all sections of the precertification form are completed and legible and that supporting clinical notes and labs are attached when requested.

Omitted baseline eosinophil count, missing documentation of prior biologics or reasons for discontinuation, or lack of evidence of prior high‑dose ICS + controller therapy may lead to denial
Incomplete prescriber or facility identifiers (NPI, state license) or missing contact/fax numbers may delay processing
Failure to document improvement for continuation requests (reduced exacerbations or oral steroid use) may result in non‑coverage

Background

Cinqair (reslizumab) is a monoclonal antibody biologic indicated for use in patients with asthma; the precertification form collects essential baseline and safety information to support initiation and ongoing therapy. For initial therapy the form requests a baseline blood eosinophil count (measured before significant oral steroid use), prior biologic use, and documentation of uncontrolled asthma or inadequate control despite high‑dose inhaled corticosteroid plus an additional controller. For continuation/recertification the form requires documentation that the patient is receiving the medication (including samples or manufacturer assistance when applicable) and evidence of clinical improvement, such as reduced frequency/severity of symptoms or reduction in daily maintenance oral corticosteroid dose.

Key Definitions

inv-13: Baseline blood eosinophil count

DefinitionBaseline blood eosinophil count = the patient's blood eosinophil count (cells per microliter) measured prior to significant oral steroid use, required for initial requests.

Required forInitial precertification requests for Cinqair (reslizumab).

Where to recordEntered on the 'For Initial Requests' clinical information section of the form.

inv-14: Uncontrolled asthma

Uncontrolled asthma criteria (exacerbations)Two or more asthma exacerbations requiring oral or injectable corticosteroids in the past year OR one or more exacerbation resulting in hospitalization or emergency medical care visit in the past year.

Uncontrolled asthma criteria (symptoms)Poor symptom control within the past year defined as frequent symptoms or reliever use, activity limitation due to asthma, or night waking from asthma.

Documentation on formProviders must complete checkboxes in the Initial Requests section indicating which uncontrolled asthma criterion applies; for continuation requests, improvement must be documented on the continuation section.

Relation to therapyEvidence of uncontrolled asthma is required as part of initial-therapy coverage criteria; clinical improvement is required for continuation requests.