CurrentAetnaPolicy N/A

Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) precertification request form coverage criteria

Precertification request form and requirements for Aetna members when initiating or continuing Phesgo therapy for breast cancer; intended for providers submitting authorization requests.

Policy Summary

PayerAetna

PolicyPhesgo precertification request form coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification is required via this form; submit complete patient, insurance, prescriber, dispensing, product, diagnosis, and required clinical information including HER2 status and treatment setting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesdocument length

Required clinical fieldsclinical info required

Aetna contactcontact info

Medicare noteMA Part B

Coverage and Clinical Criteria

Precertification documentation criteria

Coverage consideration requires documentation that the patient has HER2‑positive breast cancer and specification of the clinical treatment setting and prior therapy duration. Precertification must include complete administrative and clinical fields as indicated on the form.

Precertification documentation requirements: Provider must submit complete patient, insurance, prescriber, dispensing, product, diagnosis, and required clinical information including: documentation that the diagnosis is breast cancer; HER2 status (positive, negative, or unknown); the clinical setting (neoadjuvant, adjuvant, metastatic, recurrent, or other with explanation); whether the drug will be used in combination with chemotherapy; and the duration (months) of prior therapy for continuation requests.

All required clinical information must be completed in its entirety on the precertification form. For continuation requests, indicate if there is evidence of unacceptable toxicity or disease progression and report total months of therapy; also indicate if the patient has received ≥12 months (52 weeks) of the requested medication when applicable.

The precertification form captures the clinical contexts in which Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) may be requested for breast cancer, including neoadjuvant, adjuvant, metastatic, and recurrent disease. The form requires documentation of the patient’s HER2 status (positive/negative/unknown) and asks providers to indicate specific clinical features (for example, node-positive disease or tumour size for adjuvant and neoadjuvant settings) to support the requested use. The form does not list explicit clinical exclusions; instead it records the treatment setting and relevant clinical details to inform the authorization decision.

Policy Summary

PayerAetna

PolicyPhesgo precertification request form coverage criteria

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.

For continuation (renewal) requests the form requires documentation that addresses ongoing clinical status and prior therapy duration. Providers must indicate whether there is evidence of unacceptable toxicity or disease progression on the current regimen, and report the number of months the patient has received the requested medication. The form also asks whether the patient has received the drug for 12 months (52 weeks or greater), and the clinical setting under which continuation is requested; findings of progression or unacceptable toxicity documented on the form may affect continued coverage.

Regimen	Clinical settings documented on form	Notes
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) with or without chemotherapy
Neoadjuvant (pre-operative) treatment of breast cancer; Adjuvant therapy; Treatment of recurrent disease; Metastatic disease; Other (explain)
Form requires documentation of HER2 status and whether Phesgo will be used in combination with chemotherapy; duration of prior therapy is requested for continuation

Diagnosis and Administration Codes

Diagnosis Codes (to be provided)ICD-10

Primary ICD Code	Primary diagnosis ICD code (to be provided on form)
Secondary ICD Code	Secondary diagnosis ICD code (to be provided on form)
Other ICD Code	Other diagnosis ICD code (to be provided on form)

Administration CPT Codes (to be provided)CPT

Administration code(s) (CPT)

Administration CPT code(s) — checkbox provided on form to list codes

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization (precertification) is required before initiating Phesgo®. Submit the completed Phesgo® (pertuzumab, trastuzumab, and hyaluronidase-zzxf) Medication Precertification Request form. All form fields must be completed and legible. The plan may request additional information or clarification as needed to evaluate requests.

Indicate whether request is Start of treatment (include start date) or Continuation (include date of last treatment)
Precertification Requested By: name, phone, fax must be provided
For Medicare Advantage Part B use the Medicare Request Form

Documentation Required

Therapy Context and Duration Documentation

Document the clinical context and duration for both initiation and continuation requests. For initiation, specify the breast cancer setting (neoadjuvant, adjuvant, metastatic/recurrent), HER2 status, node-positive/high-risk status if adjuvant, and whether the drug will be used in combination with chemotherapy. For continuation, document any unacceptable toxicity or disease progression, how many months the patient has received the requested medication, and whether therapy has reached 12 months (52 weeks) or greater when applicable.

Select clinical setting: Neoadjuvant (pre-operative), Adjuvant, Metastatic, Recurrent, Other (explain)
State HER2 status: HER2 positive / HER2 negative / Unknown
If adjuvant: indicate node-positive or high risk for recurrence (Yes/No)
Indicate whether used with chemotherapy (Yes/No)
Report how many months of therapy patient has received; for continuation, indicate if ≥ 12 months (52 weeks)

Documentation Required

Required Documentation for Initiation and Continuation Requests

All required clinical information and all form fields must be completed and legible for both initiation and continuation precertification requests. Incomplete submissions will delay review. Include dates (start of treatment or date of last treatment), signature and date on the acknowledgement section, and contact information for the requestor.

For initiation: complete all applicable clinical setting questions and HER2 status
For continuation: indicate toxicity/progression status and duration received
Request Completed By: signature and date required

Denial Risk

Incomplete or False Information — Denial and Fraud Risk

Providing materially false or intentionally incomplete information is fraud. Knowingly filing a request with the intent to injure, defraud or deceive the plan, or concealing material information, may result in denial of the request and civil or criminal penalties.

Materially false or incomplete submissions may be denied
Fraudulent acts may be subject to criminal and civil penalties
Aetna may request additional information or clarification to evaluate requests

Line(s) of Therapy

First‑line

Covered when the documented clinical setting corresponds to first‑line use as indicated on the form.

Clinical setting options: Neoadjuvant (pre‑operative) treatment of breast cancer; Adjuvant therapy (document node‑positive or high‑risk status as applicable); Treatment of recurrent disease; Metastatic disease; Other (explain).

Form captures which setting applies; it does not itself mandate a numeric line number but is used to identify first‑line clinical context for the request.

HER2 and Biomarker Documentation

inv-13: HER2 — checkbox values

HER2 positiveCheckbox option to document HER2-positive status

HER2 negativeCheckbox option to document HER2-negative status

Unknown HER2 statusCheckbox option when HER2 status is not known

inv-11: HER2 status — field and relevance

Field nameHuman epidermal growth factor receptor 2 (HER2) status

PurposeRequired clinical information to document appropriateness of Phesgo for breast cancer precertification requests

Accepted entriesHER2 positive; HER2 negative; Unknown (select one)

When requiredMust be completed for initiation requests and included with other clinical setting information

Permitted Regimens and Settings

Regimen	Indications documented on form	Required documentation elements
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) with or without chemotherapy
Neoadjuvant (pre-operative), Adjuvant, Metastatic, Recurrent, Other (explain)
HER2 status (positive/negative/unknown), clinical setting selection, whether combined with chemotherapy, months of prior therapy (for continuation), evidence of unacceptable toxicity or disease progression (for continuation)

Background

Phesgo is a combination product composed of pertuzumab, trastuzumab, and hyaluronidase-zzxf used for the treatment of HER2-positive breast cancer. The precertification form is intended to document the patient’s HER2 status and the clinical treatment setting (neoadjuvant, adjuvant, metastatic, or recurrent) to support initiation or continuation of therapy.