CurrentAetnaPolicy N/A

Somavert (pegvisomant) Medication Precertification Request

This form governs Aetna precertification requests for Somavert (pegvisomant) for members (initiation and continuation of therapy) and specifies required clinical, administrative, and dispensing information to determine coverage.

Policy Summary

PayerAetna

PolicySomavert (pegvisomant) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest precertification via Aetna's phone or fax notification process and submit required clinical documentation including IGF-1 levels.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pageform length

Requiredclinical documentation

Phone/Faxcontact methods

YesIGF-1 required

Coverage Criteria for Somavert (pegvisomant)

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Initiation criteria: 1) Diagnosis of acromegaly; 2) Documentation whether the patient had an inadequate or partial response to surgery or radiotherapy OR a documented clinical reason why surgery/radiotherapy was not performed; 3) Pretreatment IGF-1 level reported relative to the laboratory reference normal range based on age and/or gender (higher, lower, or within range); 4) Complete prescriber and dispensing information provided on the precertification form.

All items are requested on the form for initiation.

Continuation Requests

Covered when ALL of the following are documented:

Continuation criteria: 1) Ongoing therapy with Somavert (pegvisomant); 2) Documentation of how IGF-1 changed since initiation of therapy (increased, decreased/normalized, or unchanged); 3) Date of last treatment provided; 4) Continued prescriber and dispensing information provided on the precertification form.

Form asks for IGF-1 trend to support continuation.

The form does not list specific exclusions for Somavert (pegvisomant); however, approvals depend on completion of required clinical fields. Lack of documentation regarding prior surgery or radiotherapy status, or missing pretreatment IGF-1 values relative to the laboratory reference range, may preclude approval because these items are required for initiation and are explicitly requested on the form.

Requests must be complete and legible. The form states that knowingly filing a request with materially false information or concealing material information constitutes a fraudulent insurance act and may result in criminal and civil penalties. The plan may also request additional information or clarification; failure to provide accurate or requested documentation can lead to denial or delay of coverage.

Provider Submission and Documentation Requirements

Prior Authorization

Precertification required

Precertification must be requested via Aetna's notification process (phone/fax) for Somavert prior to initiation or continuation of therapy.

Phone: 1-866-752-7021 (TTY: 711)
FAX: 1-888-267-3277
For Medicare Advantage Part B: Use Medicare Request Form

Documentation Required

Prior surgery/radiotherapy information

Form asks whether the patient had an inadequate or partial response to surgery or radiotherapy and requests a clinical reason if surgery or radiotherapy was not performed. For initiation requests, indicate the patient's pretreatment IGF-1 level relative to the laboratory's age/gender reference range.

Has the patient had an inadequate or partial response to surgery or radiotherapy? (Yes/No)
If surgery/radiotherapy not performed, provide clinical reason
Indicate pretreatment IGF-1 compared to laboratory normal range (higher/lower/within)

Documentation Required

Required documentation

Submit complete patient demographics, insurance and prescriber details, product (Somavert) dose and frequency, primary and secondary ICD codes, and required clinical documentation (see initiation vs continuation sections). Incomplete or illegible information may delay review.

Patient demographics: name, DOB, address, contact numbers, weight and height, allergies
Prescriber details: name, credentials, address, phone, fax, NPI, state license, specialty
Product: Somavert (pegvisomant) — dose and frequency
Diagnosis: primary ICD code, secondary/other ICD codes
Clinical documentation: for initiation — pretreatment IGF-1 and surgery/radiotherapy history; for continuation — IGF-1 change since therapy start

Denial Risk

Incomplete or missing information

Failure to provide complete and legible precertification information or to supply requested additional information may result in denial or delayed processing of the request.

Request completed by signature and date required
Plan may request additional information or clarification as needed

Key Definitions

IGF-1 (definition and form requirements)

TermIGF-1 (Insulin-like growth factor 1)

Initiation requirementPretreatment IGF-1 reported relative to the laboratory's reference normal range based on patient age and/or gender (higher, lower, or within normal range)

Continuation requirementDocumentation of change in IGF-1 since initiation (increased, decreased/normalized, or unchanged)

Context of useRequired clinical information on the Somavert precertification form for both initiation and continuation requests

Implication if missingLack of IGF-1 documentation may preclude approval of the request

Background

Somavert (pegvisomant) is indicated for the treatment of acromegaly. The precertification form requires documentation that the patient has acromegaly and asks whether the patient had an inadequate or partial response to surgery or radiotherapy or, if not performed, a clinical reason why these treatments were not done. For initiation requests the form requires the patient's pretreatment IGF-1 level reported in relation to the laboratory's age/gender reference range. For continuation requests the form asks for how IGF-1 has changed since initiation to support ongoing therapy.