CurrentAetnaPolicy N/A

Imlygic (talimogene laherparepvec) Medication Precertification Request

Precertification request form and instructions for Aetna coverage review of Imlygic (talimogene laherparepvec), used primarily for melanoma treatment; applies to providers requesting prior authorization for Aetna members.

Policy Summary

PayerAetna

PolicyImlygic (talimogene laherparepvec) Medication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification must be requested by phone or fax using Aetna's form prior to initiation or continuation of Imlygic therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pageform length

phone & fax providedprecertification contact info

melanomaindicated primary disease

requires clinical documentationclinical info mandatory for requests

Coverage Determination Criteria

Coverage determination requires submission of a completed form with the following clinical and diagnosis information. All required fields must be completed for precertification requests; incomplete forms may delay or result in denial of coverage.

ALL of the following

Product information: drug name (Imlygic - talimogene laherparepvec), requested dose, and frequency must be provided.
From product information section.
Diagnosis information: primary ICD-10 code must be provided; include secondary and other ICD-10 codes where applicable.
From diagnosis information section.
Clinical information (required for all requests): specify melanoma disease type by checking applicable option(s): cutaneous melanoma; subcutaneous melanoma; nodal lesions in melanoma; or other.
From clinical information section.

Policy Summary

PayerAetna

PolicyImlygic (talimogene laherparepvec) Medication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification must be requested by phone or fax using Aetna's form prior to initiation or continuation of Imlygic therapy.

SourceLink

On This Page

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Provider Actions & Precertification Requirements

Prior Authorization

Prior Authorization Required

Precertification must be requested by phone or fax using Aetna's form prior to initiation or continuation of Imlygic therapy.

Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277
For Medicare Advantage Part B: Use Medicare Request Form
Indicate if request is Start of treatment (include start date) or Continuation of therapy (include date of last treatment)

Documentation Required

Clinical Setting Documentation

Form asks the provider to indicate the clinical setting and lesion details. Complete all clinical fields for initial and continuation requests; for continuation requests, document whether there is evidence of unacceptable toxicity or disease progression while on the current regimen.

Clinical disease type: cutaneous, subcutaneous, nodal lesions, or other
Clinical setting: unresectable, limited resectable, incompletely resectable, or other
For continuation: indicate evidence of unacceptable toxicity or disease progression (Yes/No)

Billing Rule

Administrative & Billing Information

Complete administrative and billing information in its entirety on the precertification form to avoid delays in review and payment.

Patient demographics: name, address, DOB, contact numbers, weight, height, allergies
Insurance information: Aetna Member ID, other coverage details, Medicare/Medicaid IDs if applicable
Prescriber details: name, license type, address, phone, fax, state license number, NPI, DEA, UPIN, specialty
Dispensing/administration site: place of administration, center name, phone, address, TIN/PIN
Product information: medication name (Imlygic), dose, frequency, administration CPT codes where applicable
Diagnosis: primary and secondary ICD codes

Denial Risk

Fraud and Misrepresentation

Providing materially false information or concealing material information for the purpose of misleading the plan is fraudulent and may result in denial of the request and civil or criminal penalties. The plan may request additional information or clarification as needed to evaluate requests.

Signature required: Request Completed By (signature and date)
Fraud statement: filing with intent to defraud is a crime and may subject the filer to criminal and civil penalties

Definitions and Clinical Setting Enumerations

Continuation Requests — definition and required verification fields

DefinitionA continuation request is a precertification request submitted to continue ongoing Imlygic (talimogene laherparepvec) therapy (i.e., not an initiation request).

Required verification — toxicity/progressionFor continuation requests, document whether there is evidence of unacceptable toxicity or disease progression while on the current regimen (Yes or No).

Required clinical documentationComplete the required clinical information in its entirety for all continuation requests as specified on the form (melanoma lesion type, clinical setting, and response/toxicity status).

Form signatureRequest must include the completed form with signature/date in the acknowledgement section as part of the submission.

Clinical setting — enumerated options

Unresectable diseaseSelect this when the patient's melanoma is not amenable to surgical resection.

Limited resectable diseaseSelect this when the disease is resectable but extent is limited (provider to indicate on form).

Incompletely resectable diseaseSelect this when surgical resection is possible but would be incomplete (residual disease expected).

Other — clinical settingAn option is provided to indicate other clinical settings not captured by the listed categories.

Primary ICD Code	Primary diagnosis ICD code to be provided
Secondary ICD Code	Secondary diagnosis ICD code to be provided
Other ICD Code	Additional diagnosis ICD code to be provided

OpenPayer

Imlygic (talimogene laherparepvec) Medication Precertification Request

Coverage Determination Criteria

Coding / Billing Information

Provider Actions & Precertification Requirements

Clinical Background

Definitions and Clinical Setting Enumerations