Nucala_Precertification_Request
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Aetna precertification request form to collect patient, prescriber, dispensing, diagnosis, and clinical information for authorization review for Nucala (mepolizumab) in multiple labeled indications (asthma, CRSwNP, EGPA, HES). It defines required fields and clinical questions to support prior authorization review; it does not itself state coverage criteria or billing codes.
No material changes — this is an administrative precertification form with no material clinical/coverage changes.
Policy overview & purpose
This is an Aetna precertification request form titled Nucala (mepolizumab) Injectable Medication Precertification Request used to collect patient, prescriber, dispensing/administration, product, diagnosis (ICD code) and indication-specific clinical information needed for utilization review across labeled indications including asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), eosinophilic granulomatosis with polyangiitis (EGPA), and hypereosinophilic syndrome (HES).
The form captures required fields for authorization review (e.g., patient demographics, prescriber and dispensing details, requested product dose/frequency, primary and secondary ICD codes, and indication-specific clinical checklists) but the form itself does not state coverage criteria or billing codes; providers must supply administration CPT code(s) when applicable and complete all required clinical fields for precertification review.
Required clinical information for precertification review
Required clinical information for precertification review (by indication)
Form requires completion of the following clinical items for any request; indication-specific checklists follow.
General required items (for all requests)
- Is this infusion request in an outpatient hospital setting? (Yes/No) - document if applicable
- Has the patient experienced an adverse event with the requested product that has not responded to conventional interventions or a severe adverse event during or immediately after an infusion? (Yes/No)
Examples: acetaminophen, steroids, diphenhydramine, fluids, anaphylaxis, myocardial infarction, thromboembolism, seizures
- Does the patient have significant behavioral issues and/or physical or cognitive impairment that would impact infusion safety AND lack of caregiver? (Yes/No) - provide description if yes
- Is the patient medically unstable which may limit tolerance of a large volume/load or predispose to severe adverse event? (Yes/No) - provide description and indicate cardiovascular, respiratory, renal, or other
- Will the requested drug be used concomitantly with any other biologic or targeted synthetic drug for the same indication? (Yes/No)
Examples: Adbry, Humira, Dupixent, Rinvoq, Olumiant, Otezla, Xeljanz
Asthma-specific questions
- Baseline blood eosinophil count in cells per microliter - provide value
- Is the medication prescribed by or in consultation with an allergist, immunologist, or pulmonologist? (Yes/No)
- Prior biologic therapy for asthma? (Yes/No) - e.g., Dupixent, Xolair
- Uncontrolled asthma: ≥2 exacerbations requiring oral or injectable corticosteroid in past year? (Yes/No)
- Uncontrolled asthma: ≥1 exacerbation resulting in hospitalization or emergency medical care visit in past year? (Yes/No)
- Uncontrolled asthma: poor symptom control (frequent symptoms/reliever use, activity limitation, night waking) within past year? (Yes/No)
- Inadequate asthma control despite high-dose inhaled corticosteroid plus additional controller at optimized doses prior to requested medication? (Yes/No)
- Is the patient dependent on systemic corticosteroids? (Yes/No)
- Will patient continue maintenance asthma treatments in combination with requested medication? (Yes/No)
Chronic rhinosinusitis with nasal polyps (CRSwNP) questions
- Is the medication prescribed by or in consultation with an allergist/immunologist or otolaryngologist? (Yes/No)
- Prior biologic therapy for CRSwNP? (Yes/No)
- Bilateral nasal polyps and chronic sinusitis symptoms? (Yes/No)
- Intranasal corticosteroid treatment for at least 2 months? (Yes/No)
- Are intranasal corticosteroids contraindicated or not tolerated? (Yes/No)
- Prior sino-nasal surgery? (Yes/No)
- Inadequate response with systemic corticosteroids within last 2 years? (Yes/No)
- Are systemic corticosteroids contraindicated or not tolerated? (Yes/No)
- Bilateral nasal endoscopy/anterior rhinoscopy/CT showing polyps reaching below lower border of middle turbinate or beyond in each nostril? (Yes/No)
- Meltzer Clinical Score ≥2 in both nostrils? (Yes/No)>= 2 in both nostrils
- Total endoscopic nasal polyps score (NPS) ≥5 with minimum score of 2 each nostril? (Yes/No)>= 5 total with minimum 2 per nostril
- Symptoms: nasal blockage/congestion/obstruction? (Yes/No)
- Symptoms: rhinorrhea, loss of smell, or facial pain/pressure? (Yes/No)
- Will patient continue daily intranasal corticosteroid while treated? (Yes/No)
Eosinophilic granulomatosis with polyangiitis (EGPA) questions
- History or presence of blood eosinophil count >1000 cells/µL or eosinophil level >10%? (Yes/No) - indicate which> 1000 cells per microliter or > 10%
- Presence of additional EGPA features (biopsy with eosinophilic vasculitis/perivascular infiltration/granulomatous inflammation, neuropathy, pulmonary infiltrates non-fixed, sino-nasal abnormality, cardiomyopathy, glomerulonephritis, alveolar hemorrhage, palpable purpura, ANCA positive)? (check applicable)
- At least one relapse within 2 years prior to starting treatment? (Yes/No)
Relapse defined as increased oral corticosteroid dose, initiation/increase of immunosuppressive therapy, or hospitalization
- Refractory disease? (Yes/No)
- Currently receiving oral corticosteroids? (Yes/No)
- Are oral corticosteroids contraindicated or not tolerated? (Yes/No)
Hypereosinophilic syndrome (HES) questions
- HES secondary to non-hematologic cause? (Yes/No)
Examples: drug hypersensitivity, parasitic infection, HIV, non-hematologic malignancy
- FIP1L1-PDGFRA kinase-positive HES? (Yes/No)
- Has HES been present for at least 6 months? (Yes/No)
- History or presence of blood eosinophil count ≥1000 cells/µL? (Yes/No)>= 1000 cells per microliter
- Will patient receive requested medication as monotherapy (without other HES medications)? (Yes/No)
- Is patient on a stable dose of HES therapy (e.g., oral corticosteroid, immunosuppressive, and/or cytotoxic therapy)? (Yes/No)
- Has patient experienced at least two HES flares within past 12 months? (Yes/No)
Continuation request items
- Is patient currently receiving medication through samples or manufacturer's patient assistance program? (Yes/No)
- Asthma: Has asthma control improved on requested medication (reduction in frequency/severity of symptoms/exacerbations)? (Yes/No)
- Asthma: Has asthma control improved demonstrated by reduction in daily maintenance oral corticosteroid dose? (Yes/No)
- Continuation: Will patient continue maintenance asthma treatments in combination? (Yes/No)
- CRSwNP: Has patient achieved or maintained positive clinical response (improvement in signs/symptoms or reduction in corticosteroid use)? (Yes/No)
- CRSwNP: Will patient continue daily intranasal corticosteroid while being treated? (Yes/No)
- EGPA: Beneficial response to treatment (reduction in relapses, reduction in daily oral corticosteroid dose, or no active vasculitis)? (Yes/No)
- HES: Has patient experienced reduction in HES flares since starting treatment? (Yes/No)
- HES: Will patient receive requested medication as monotherapy? (Yes/No)
Actions required from providers
Precertification request submission
Providers must complete and submit this precertification form with all required clinical fields legible for Aetna precertification review via phone 1-866-752-7021 (TTY:711) or fax 1-888-267-3277. For Medicare Advantage Part B requests, use the Medicare request form.
Required clinical documentation
Include indication-specific evidence as indicated on the form for authorization review — for example baseline blood eosinophil counts, history of exacerbations, prior biologic therapies, imaging/endoscopy scores (e.g., Meltzer score, nasal polyp score), biopsy or histopathologic features for EGPA, and history of HES flares.
Administration coding provided by provider
When applicable, providers must supply administration CPT code(s) on the form (the form includes a field for Administration code(s) (CPT)).
Incomplete submissions risk denial
The plan may request additional information or clarification to evaluate requests; incomplete or missing required clinical information may prevent approval. The form requires a signature; knowingly providing fraudulent or materially false information may subject the requester to criminal and civil penalties.
Form-requested coding fields
| No codes listed |
| No codes listed |
Definitions
Nucala is the brand name for mepolizumab, an injectable biologic therapy targeting IL-5.
Document changes
No documented revisions provided in brief / no material changes
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