Cinryze (C1 esterase inhibitor, human) Medication Precertification Request Form and Requirements
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Aetna precertification form and requirements for requesting initial or continuation authorization for Cinryze infusion therapy, intended for providers and facilities submitting precertification for members in North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial and Continuation Therapy Documentation Requirements
Coverage consideration requires completion of the precertification form and documentation of diagnosis and clinical response.
All required clinical information must be completed in its entirety and legible; failure to complete may prevent evaluation of the request
Select and document which diagnostic criteria apply on the form
Form includes checkbox asking whether specialist is involved
Continuation therapy response
- Attack frequency reduction: Patient experienced a significant reduction in frequency of acute HAE attacks (example threshold: >= 50% reduction)>= 50% reduction in frequency of acute attacks
Document number of HAE attacks per month before and after treatment on the form
- Reduced acute-attack medication use: Patient has reduced the use of medications to treat acute HAE attacks since starting the requested medication
Document types and frequency of acute-attack medications used before and after treatment
Form includes specific checkboxes and request for descriptive details for these scenarios
The precertification form includes a specific question asking whether the requested medication will be used in combination with any other medication used for the prophylaxis of hereditary angioedema (HAE) attacks. Providers must indicate combination use on the form when applicable so that concurrent prophylactic therapy is clear for the reviewer.
Failure to provide required clinical information in full may prevent the reviewer from evaluating the request and can result in denial or requests for additional information. The form explicitly states that required clinical information must be completed in its entirety for all precertification requests, including diagnosis confirmation, attack frequency, prior therapy response, and relevant infusion safety details.
Coding
| Administration code(s) (CPT): | Placeholder on form for provider to supply applicable CPT administration codes |
| Primary ICD Code, Secondary ICD Code, Other ICD Code | Placeholders for ICD-10 diagnosis codes relevant to HAE and other diagnoses |
Provider Actions / Submission Requirements
Precertification required — contact Aetna Precertification Notification
Precertification (prior authorization) is required for Cinryze. Contact Aetna Precertification Notification by phone or fax and submit the completed form to initiate review.
- Phone: 1-866-752-7021
- Fax: 1-888-267-3277
- Submit the completed Cinryze medication precertification request form with all fields legible
Requirements for HAE with normal C1‑INH
When requesting Cinryze for HAE with normal C1‑INH, include objective genetic testing results or documentation that angioedema was refractory to a trial of high‑dose antihistamine and a family history, as specified on the form.
- Genetic testing showing mutation in F12, angiopoietin‑1, plasminogen, KNG1, HS3ST6, or MYOF
- OR documentation of angioedema refractory to high‑dose antihistamine (e.g., cetirizine 40 mg/day or equivalent for ≥1 month) plus family history of angioedema
Complete and legible two‑page form submission required
Submit the completed two‑page Cinryze medication precertification request form with all fields legible, including patient demographics, insurance, prescriber and dispensing provider details, product dose/frequency, ICD codes, and required clinical information.
- Required clinical information: diagnosis confirmation, lab or genetic test results, number of HAE attacks, prior therapy response, and continuation outcomes
- Indicate whether prescribed by or in consultation with an HAE specialist
Incomplete clinical information may lead to denial or inability to evaluate request
Failure to complete the required clinical information in its entirety for all precertification requests may prevent evaluation of the request and can result in denial or requests for additional information.
- Ensure sections G (Clinical Information) and the continuation therapy questions are fully completed
- Provide lab values, genetic test results, trial details (e.g., antihistamine dose/duration), and response data
Background
Cinryze is a human C1 esterase inhibitor indicated for prevention of hereditary angioedema (HAE) attacks. The precertification form requests documentation confirming the HAE diagnosis (laboratory or genetic testing as applicable) and clinical response information for continuation requests, such as reduction in attack frequency and decreased use of acute-attack medications.
Definitions
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