CurrentAetnaPolicy N/A

Precertification request form for intravenous iron: Feraheme and Injectafer

This document is Aetna's precertification request form used by providers to request authorization for administration or continuation of ferumoxytol (Feraheme) or ferric carboxymaltose (Injectafer) for insured members. It applies to providers submitting prior authorization requests for these IV iron products.

Policy Summary

PayerAetna

PolicyPrecertification request form for intravenous iron: Feraheme and Injectafer

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed precertification form with administration CPT code(s) and recent ferritin/TSAT labs (drawn within 30 days when applicable).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

requiredclinical info

30 dayslab recency

Aetnapayer contact

Coverage Criteria for IV Iron Precertification

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inv-01: Coverage criteria for IV iron precertification

Covered when ALL of the following are documented on the precertification form

Required clinical laboratory documentation: Provider documents recent serum ferritin and transferrin saturation (TSAT) levelslabs within 30 days

From form: 'Please indicate the patient's serum ferritin level' and 'Was the serum ferritin and/or transferrin saturation level drawn within the last 30 days?'

Clinical indication (one of): Patient has one of the listed clinical indications: iron deficiency anemia associated with chronic kidney disease (specify non-dialysis dependent or peritoneal dialysis), unable to tolerate oral iron, ongoing blood loss too rapid for oral iron to compensate, gastrointestinal disorder aggravated by oral iron (e.g., inflammatory bowel disease), unable to maintain iron balance on hemodialysis, donating large amounts of blood for autologous programs, failure or inability to adhere to oral iron, heart failure with iron deficiency (with or without anemia), iron deficiency and chemotherapy-induced anemia, heavy uterine bleeding causing iron deficiency anemia, or iron deficiency after gastric bypass/subtotal gastric resection with decreased absorption of oral iron

Indications enumerated on the form

Product and administration details: Provider specifies product requested (Feraheme or Injectafer), dose, frequency, place of administration, and administration CPT code(s) as applicable

Product and administration fields on form; administration place options and CPT code(s) to be provided by submitting provider

Covered Regimen	Indication / Notes	Coverage
IV ferumoxytol (Feraheme) or IV ferric carboxymaltose (Injectafer)
Iron deficiency (including causes such as heavy uterine bleeding, post-gastric bypass decreased absorption, ongoing blood loss, GI disorders, inability to tolerate or adhere to oral iron)
Covered when required clinical information is completed on the precertification form, including recent serum ferritin and TSAT as applicable and documentation of indication
IV ferumoxytol (Feraheme) or IV ferric carboxymaltose (Injectafer)
Chemotherapy-induced anemia
Covered when required clinical information is completed on the precertification form, including recent serum ferritin and TSAT as applicable and documentation of indication

Coding and Laboratory Requirements

Administration CPT CodesCPT

Administration code(s) (CPT)

Administration CPT codes to be provided by the submitting provider as applicable

Diagnosis ICD-10 CodesICD-10

Primary ICD Code	Primary diagnosis ICD code to be specified by provider
Secondary ICD Code	Secondary diagnosis ICD code to be specified by provider

Recency of ferritin/TSAT labs — drawn within the last 30 days

Required lab recencySerum ferritin and/or transferrin saturation (TSAT) must be drawn within the last 30 days

Labs requiredProvider must report current serum ferritin level

TSAT requiredProvider must report current transferrin saturation (TSAT) level

Continuation requestsIndicate if this is a request for continuation of therapy

Provider Actions and Submission Requirements

Prior Authorization

Precertification Required

Precertification is required for Feraheme and Injectafer. Providers must submit the Feraheme/Injectafer Medication Precertification Request form and include the administration CPT code(s) with the submission. All fields on the form must be completed and legible for precertification review; missing or incomplete clinical information may prevent approval.

Aetna Precertification Phone: 1-866-752-7021; Fax: 1-888-267-3277
Medicare Advantage Part B Precert Phone: 1-866-503-0857; Fax: 1-844-268-7263
Form: Feraheme® (ferumoxytol) and Injectafer® (ferric carboxymaltose) Medication Precertification Request — all fields required

Step Therapy

Prior Therapy Considerations

The precertification form asks whether the patient has a contraindication, intolerance, or ineffective response to other IV iron products (Ferrlecit, Infed, or Venofer). Indicate prior therapy status on the form; this prior therapy information will be considered in the review.

Question on form: "Does the patient have a contraindication, intolerance or ineffective response to Ferrlecit, Infed, or Venofer?" (Yes/No)
For non-CKD indications, the form documents inability to tolerate oral iron, excessive blood loss, GI disorders (e.g., IBD), or inability to maintain iron balance on hemodialysis

Documentation Required

Required Documentation

Required documentation includes full patient demographics, prescriber information (including state license number and NPI), product requested (Feraheme or Injectafer), dose and frequency, diagnosis ICD code(s), and recent laboratory values. Complete clinical data is required for all requests.

Patient information: name, DOB, address, contact numbers, weight, height, allergies
Prescriber information: name, credentials (MD/DO/NP/PA), address, phone, fax, state license number, NPI, DEA, specialty
Product information: selected product (Feraheme or Injectafer), dose, frequency
Diagnosis: primary ICD code (and secondary/other codes as applicable)
Clinical labs: serum ferritin level and transferrin saturation (TSAT) level — indicate whether drawn within last 30 days

Denial Risk

Incomplete Clinical Data

Incomplete or missing clinical information may prevent precertification approval. Ensure serum ferritin and TSAT are provided (and indicate if drawn within the last 30 days), and complete the continuation of therapy information if applicable.

Form must state if request is start of treatment or continuation and provide date of last treatment for continuations
If chronic kidney disease indication, indicate CKD-associated iron deficiency anemia status and whether patient is non-dialysis dependent (NDD) or undergoing peritoneal dialysis
For all requests: completion of section G (Clinical Information) is required

Clinical Definitions and Lab Criteria

NDD / peritoneal dialysis — Non-dialysis dependent (NDD) or peritoneal dialysis status for CKD patients

CKD status questionForm asks whether the patient has iron deficiency anemia associated with chronic kidney disease

NDD optionThe form includes ‘The patient is non-dialysis dependent (NDD)’ as a selectable status

Peritoneal dialysis optionThe form includes ‘The patient is undergoing peritoneal dialysis’ as a selectable status

Not CKD optionForm provides a ‘No’ option indicating the patient does not have CKD-related iron deficiency anemia

Ferritin and TSAT — serum ferritin and transferrin saturation (TSAT) levels and recency requirement

Ferritin measurementProvider must indicate the patient’s serum ferritin level on the form

TSAT measurementProvider must indicate the patient’s transferrin saturation (TSAT) level on the form

Recency confirmationForm requires the provider to confirm whether the ferritin and/or TSAT were drawn within the last 30 days

Clinical documentation requirementRequired clinical information (including ferritin and TSAT) must be completed in its entirety for all precertification requests

Background

This precertification request form is used to collect the clinical and administrative information necessary to support medical necessity for intravenous iron therapy with Feraheme (ferumoxytol) or Injectafer (ferric carboxymaltose). The form captures patient demographics, prescriber and administration details, the specific product, dose and frequency, primary diagnosis code(s), and required clinical data such as serum ferritin and transferrin saturation (TSAT) with confirmation of whether these labs were drawn within the last 30 days. It also documents relevant clinical indications (including CKD-related status, intolerance to oral iron, ongoing blood loss, GI disorders, hemodialysis considerations, and other listed reasons) to support authorization decisions.