CurrentAetnaPolicy N/A

Filgrastim Precertification Request

Precertification documentation and clinical information requirements for Aetna coverage review of filgrastim products (Granix, Neupogen, Nivestym, Releuko, Zarxio) submitted by providers for members.

Policy Summary

PayerAetna

PolicyFilgrastim Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification is required for filgrastim products and must be requested using the Aetna precertification form; contact Aetna Precertification Notification by phone or fax as provided on the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5filgrastim product options listed

3document pages

1-866-752-7021precert phone

1-888-267-3277precert fax

Coverage Criteria

Coverage criteria by indication

Policy Summary

PayerAetna

PolicyFilgrastim Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General required elements: Provider submits complete patient demographics, insurance, prescriber and dispensing provider information, selected filgrastim product and dose, primary ICD diagnosis, and ANC with date obtained

See form sections A–F and G for required fields

Indications supported by form: Includes: hematopoietic syndrome of acute radiation syndrome; neutropenia associated with HIV/AIDS; neutropenia prevention or treatment associated with myelosuppressive anti-cancer therapy (primary/secondary prophylaxis); treatment of high-risk febrile neutropenia; neutropenia in myelodysplastic syndrome; neutropenia related to renal transplantation; stem cell transplantation-related indications; severe chronic neutropenia (cyclic, congenital, idiopathic); other listed indications

Select appropriate indication boxes on form

Secondary prophylaxis: If used as secondary prophylaxis, documentation must show prior neutropenic complication or febrile neutropenia from a prior similar chemotherapy cycle and that planned cycle will use same dose and schedule

Form queries prior FN and dose/schedule consistency

Treatment of febrile neutropenia or prolonged neutropenia: For treatment of high-risk febrile neutropenia or prolonged/profound neutropenia, documentation of prognostic factors or expected neutropenia duration/ANC thresholds is requiredprolonged >10 days or ANC <1 x10^9/L

Prognostic factors listed include age>65, hospitalization, sepsis, invasive fungal infection, pneumonia

The precertification form specifically asks whether the requested filgrastim product will be used in combination with any other colony-stimulating factor during any chemotherapy cycle. Providers must indicate the exact filgrastim product requested (Granix, Neupogen, Nivestym, Releuko, or Zarxio) and answer whether the medication will be used as supportive care for neutropenia or to treat neutropenic fever following chemotherapy. These combination‑use and product‑selection questions are required fields on the form and are used to determine appropriate coverage and to identify whether step‑therapy/biosimilar trial rules may apply.

Requests lacking required clinical information will be considered administratively incomplete and may be denied. The form requires the patient's absolute neutrophil count (ANC) and the date obtained, the indication for filgrastim, documentation of whether the patient has a nadir count requiring immediate treatment, and whether the patient has tried and failed Zarxio because of a documented intolerable adverse event. Incomplete, illegible, or materially false information may result in denial or fraud investigation as described in the acknowledgement section.

Coding

Administration CPT codes (placeholder)CPT

Administration code(s) (CPT)

Place on form for administration CPT codes

Diagnosis codesICD-10

Primary ICD code

Primary diagnosis ICD code to be specified by provider

inv-06: Prolonged or profound neutropenia — criterion detail (neutropenia expected >10 days or ANC < 1 x 10^9/L)

Prolonged neutropeniaNeutropenia expected to last greater than 10 days

Profound neutropeniaAbsolute neutrophil count (ANC) less than 1 x 10^9/L

Use caseRequired documentation for treatment of high‑risk febrile neutropenia or prolonged/profound neutropenia

inv-07: Chemotherapy febrile neutropenia risk — ≥20% risk or 10-19% risk as indicated on form.

High chemotherapy FN riskMyelosuppressive anti‑cancer therapy expected to result in 20% or higher incidence of febrile neutropenia

Intermediate chemotherapy FN riskMyelosuppressive therapy expected to result in 10–19% incidence of febrile neutropenia (use when form indicates and with at least two patient‑related risk factors)

Risk factorsPatient‑related risk factors listed on form include age ≥65, prior FN, bone marrow involvement, active infection/open wounds/recent surgery, poor nutritional or performance status, comorbidities (e.g., renal/liver dysfunction, HIV, cardiovascular disease)

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Precertification is required for filgrastim products. Submit requests using the Aetna Filgrastim Precertification Request form and include all required sections: patient demographics, clinical information, prescriber and dispensing provider details, product selection and dosing, and relevant laboratory data (absolute neutrophil count and date obtained). Contact 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.

All fields on the form must be completed and legible for precertification review.
Include start/continuation of chemotherapy dates when applicable.
Provide prescriber identifiers: state license, NPI, DEA, UPIN (if applicable), specialty and office contact information.
Document product selection (Granix, Neupogen, Nivestym, Releuko, Zarxio), dose, and directions for use.

Step Therapy

Step Therapy / Biosimilar Trial

Step therapy applies for non‑Zarxio filgrastim products. Providers must document that the patient has tried and failed Zarxio (filgrastim‑sndz) due to a documented intolerable adverse event (for example, rash, nausea, vomiting) before coverage of an alternative filgrastim product will be approved. Indicate whether the adverse event was unexpected and not attributed to the active ingredient as described in the Zarxio prescribing information.

Form includes explicit question: Has the patient tried and failed Zarxio (filgrastim‑sndz) due to a documented intolerable adverse event?
If 'Yes', describe the adverse event and confirm it was unexpected and not attributable to the active ingredient.

Documentation Required

Required Documentation Elements

Complete all required documentation fields to avoid delays or denials. Required clinical documentation includes current absolute neutrophil count (with date), indication checkboxes relevant to the request (e.g., prophylaxis, prolonged or profound neutropenia, febrile neutropenia, stem cell transplant‑related indications, etc.), and any other condition‑specific details. The signature of the requester and date are required. The plan may request additional information if needed.

Patient demographics and contact information (including weight and height).
Prescriber information and credentials, plus office contact details.
Product selection, dose, directions, and indication specifics.
Laboratory data: absolute neutrophil count and date obtained.
Requester signature and date.

Denial Risk

Incomplete or Fraudulent Requests

Incomplete, illegible, or materially false information may result in denial of the request or processing delays. Knowingly providing false or misleading information is a fraudulent insurance act and may subject the filer to criminal and civil penalties.

The plan may request additional information or clarification to evaluate requests.
Ensure all entries are accurate and signed before submission.

Background

Filgrastim and its biosimilar/tbo‑filgrastim alternatives are colony‑stimulating factors used to prevent or treat neutropenia. The form lists product options (Granix, Neupogen, Nivestym, Releuko, Zarxio) and collects clinical details to support use in settings such as supportive care for chemotherapy‑induced neutropenia, treatment of neutropenic fever after chemotherapy, stem cell transplantation indications, severe chronic neutropenia, and other specified hematologic conditions.

Definitions

inv-13: ANC — Absolute neutrophil count reporting requirement (value and date obtained)

Required ANC valueAbsolute neutrophil count (ANC) must be reported (value in cells/mm^3)

Date obtainedDate the ANC was measured must be provided on the form

ContextANC reporting is required for all precertification requests as part of the clinical information section

inv-14: Primary prophylaxis of febrile neutropenia — definition and context for primary prophylaxis use of filgrastim.

DefinitionPrimary prophylaxis: use of filgrastim to prevent febrile neutropenia in patients receiving myelosuppressive chemotherapy when FN risk meets specified thresholds

When indicatedPlanned therapy expected to result in ≥20% incidence of FN, or 10–19% incidence with at least two patient‑related risk factors

DocumentationForm requires selection of primary prophylaxis box and documentation of chemotherapy FN risk and patient risk factors

Line of Therapy

first-line | subsequent

Primary or secondary prophylaxis: Form supports use for primary prophylaxis when planned myelosuppressive anti-cancer therapy is expected to result in ≥20% incidence of febrile neutropenia OR 10-19% incidence with at least two patient-related risk factors; supports secondary prophylaxis when the patient had a neutropenic complication or febrile neutropenia from a prior similar chemotherapy cycle and the planned cycle will use the same dose and schedule

Select primary vs secondary prophylaxis and document risk factors or prior event per form