CurrentAetnaPolicy N/A

Signifor (pasireotide) Medication Precertification Request

This document is an Aetna precertification request form used to request prior authorization for Signifor (pasireotide) for initiation or continuation of therapy, capturing patient, prescriber, clinical, dispensing and billing/administration information and required clinical documentation for Cushing's disease.

Policy Summary

PayerAetna

PolicySignifor (pasireotide) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit all fields on the Signifor (pasireotide) precertification form to Aetna Precertification Notification via phone or fax prior to treatment initiation or for continuation.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Indication specified on form (Cushing's disease)

4Accepted cortisol tests (pretreatment / follow-up)

2Request types (Initiation, Continuation)

Policy summary & form purpose

This is an Aetna precertification request form for Signifor (pasireotide) used to request prior authorization for initiation or continuation of therapy for Cushing's disease. The form must be completed and legible for precertification review and can be submitted via Aetna Precertification Notification by phone or fax.

The form captures administrative and clinical elements including patient demographics (name, DOB, contact information, weight/height, allergies), insurance information (Aetna member ID, group #, other coverage/Medicare/Medicaid), and prescriber information (name, credentials, address, phone/fax, NPI, licensure, specialty).

It also collects dispensing and administration details (place of administration such as self-administered, physician office, outpatient infusion center, home infusion; administration/CPT code(s); dispensing provider type such as physician office, retail pharmacy, specialty pharmacy; and dispensing provider contact and tax identification details).

Clinical capture includes diagnosis codes (primary, secondary, other ICD codes) and the required clinical test results for initiation and continuation requests (pretreatment or follow-up cortisol assessment by specified tests). The requester must sign the form and the plan may request additional information or clarification to evaluate requests.

Required clinical documentation

Initiation Requests - Required clinical documentation

For Initiation Requests (clinical documentation required for all requests):

ALL of the following

Indication: Cushing's disease (must be specified)
ALL of the following
- ONE of
  - Urinary free cortisol (UFC) level
  - Late-night salivary cortisol
  - 1 mg overnight dexamethasone suppression test (DST)
  - Longer, low dose DST (2mg per day for 48 hours)
Document whether patient had surgery that was not curative (Yes/No)
Document whether patient is a candidate for surgery (Yes/No)

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Continuation Requests - Required clinical documentation

For Continuation Requests (clinical documentation required for all requests):

ALL of the following

ALL of the following
- ONE of
  - Urinary free cortisol (UFC) level
  - Late-night salivary cortisol
  - 1 mg overnight dexamethasone suppression test (DST)
  - Longer, low dose DST (2mg per day for 48 hours)

Required steps for request submission

Prior Authorization

Submit precertification request

Complete and submit all fields on the Signifor (pasireotide) precertification form to Aetna Precertification Notification via phone or fax prior to treatment initiation or for continuation. All fields must be completed and legible for precertification review.

Documentation Required

Provide required clinical documentation for initiation

For initiation, provide the following required clinical documentation.

Indication: Cushing's disease
Pretreatment cortisol test result — ONE of: Urinary free cortisol (UFC) level; Late-night salivary cortisol; 1 mg overnight dexamethasone suppression test (DST); Longer low-dose DST (2 mg per day for 48 hours)
Surgical history: indicate whether patient had surgery that was not curative
Candidacy for surgery: indicate whether patient is a candidate for surgery

Documentation Required

Provide required clinical documentation for continuation

For continuation, provide evidence of cortisol reduction and clinical improvement since therapy start.

Evidence of reduction in cortisol level since start of therapy by ONE of: Urinary free cortisol (UFC) level; Late-night salivary cortisol; 1 mg overnight dexamethasone suppression test (DST); Longer low-dose DST (2 mg per day for 48 hours)
Documentation of improvement in signs and symptoms of disease since start of therapy (Yes/No)

Billing Rule

Specify dispensing/provider and administration details

Specify dispensing and administration details on the form.

Place of administration options: Self-administered; Physician's Office; Outpatient Infusion Center; Home Infusion Center
Dispensing provider type options: Physician's Office; Retail Pharmacy; Specialty Pharmacy; Other
Administration code(s) (CPT): indicate any applicable CPT code(s) on the form

Documentation Required

Acknowledgement signature

The request must be completed and signed by the requester. The plan may request additional information or clarification to evaluate requests.

Policy Summary

PayerAetna

PolicySignifor (pasireotide) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit all fields on the Signifor (pasireotide) precertification form to Aetna Precertification Notification via phone or fax prior to treatment initiation or for continuation.

SourceLink

On This Page

Primary ICD Code	Field for primary ICD code to indicate diagnosis
Secondary ICD Code	Field for secondary ICD code
Other ICD Code	Field for other applicable ICD code(s)

OpenPayer

Signifor (pasireotide) Medication Precertification Request

Policy summary & form purpose

Required clinical documentation

Diagnosis and administration coding fields

Required steps for request submission

Definitions

Document changes