CurrentAetnaPolicy N/A

Korsuva (difelikefalin injection) Medication Precertification Request — Coverage Criteria

Customize your policy alerts

Sign up for all Aetna policy alerts

Know when Aetna releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Aetna precertification request form and required clinical information for coverage consideration of Korsuva for treatment of pruritus, primarily in patients with CKD on dialysis; applies to providers requesting prior authorization for initiation or continuation of therapy.

Policy Summary

PayerAetna

PolicyKorsuva (difelikefalin) precertification / coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit precertification using Aetna's form with completed checklist, documentation of CKD-associated pruritus (WI-NRS baseline), dialysis status, prior therapies tried/failed, and requested dosing within 0.5 mcg/kg per HD treatment (≤3 doses/week).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

1 phone + 1 faxcontact

WI-NRSscoring tool

0.5 mcg/kgdose limit

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAetnaPolicy N/A

Korsuva (difelikefalin injection) Medication Precertification Request — Coverage Criteria

Customize your policy alerts

Sign up for all Aetna policy alerts

Know when Aetna releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAetna

PolicyKorsuva (difelikefalin) precertification / coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

1 phone + 1 faxcontact

WI-NRSscoring tool

0.5 mcg/kgdose limit

Coverage Criteria for Korsuva (difelikefalin injection)

Initial and continuation coverage criteria

Coverage consideration requires completed clinical checklist items documenting ALL of the following for initiation and continuation as applicable.

Initial therapy: Patient has diagnosis of pruritus; requested drug will be used for moderate-to-severe pruritus; prescribed by or in consultation with a nephrologist; patient is on peritoneal dialysis or hemodialysis as applicable; pruritus is associated with chronic kidney disease (uremic pruritus) supported by baseline scoring (e.g., WI-NRS, VAS/NRS); non-uremic dermatologic and systemic causes have been considered and are not the primary cause; patient has tried and failed other pruritus treatments (e.g., antihistamines, gabapentin, pregabalin, topical emollients/analgesics) or has contraindications to those therapies; proposed dosing does not exceed 0.5 mcg/kg per hemodialysis treatment and will not exceed three doses per weekall items on form checked/documented

Modeled from the form's required clinical checklist

Continuation therapy: For continuation, patient has demonstrated a positive clinical response in pruritus symptoms (e.g., improvement of at least 4 points from baseline on the WI-NRS) and ongoing dosing remains within stated limits (≤0.5 mcg/kg per hemodialysis treatment and ≤3 doses per week)≥4-point WI-NRS improvement for continuation

Continuation response criterion appears on the form

If the member’s pruritus is primarily attributable to non-uremic dermatologic conditions (for example, drug-induced hypersensitivity, allergies, dermatitis, psoriasis) or to systemic causes (for example, liver disease, malignancy/lymphoma, post‑herpetic neuralgia, HIV), the form requires the provider to indicate this. Such non-uremic dermatologic or systemic etiologies should be considered and documented because they may exclude CKD‑associated (uremic) pruritus as the primary diagnosis for which Korsuva is being requested.

Requests that do not include the required clinical information risk denial or delay. The form specifically requires documentation that the patient has pruritus and that the indication is for moderate‑to‑severe symptoms, whether the prescriber is a nephrologist (or in consultation with one), dialysis modality (hemodialysis or peritoneal dialysis), and confirmation that the pruritus is associated with CKD using a baseline scoring tool (for example, the WI‑NRS, VAS or NRS). The checklist also asks whether prior pruritus therapies (such as antihistamines, gabapentin, pregabalin, topical emollients/analgesics) were tried and failed or are contraindicated; absence of these prior‑therapy fields may lead to a request being judged not medically necessary or require additional information.

Coding and Dose Limits

Administration CPT codes (placeholder)CPT

Administration code(s) (CPT)

Placeholder on form for relevant CPT administration codes

Dose limits — Korsuva (difelikefalin injection)

Per‑treatment weight‑based maximumDo not exceed 0.5 mcg/kg per hemodialysis treatment

Maximum frequencyDo not exceed three doses per week

Form checkbox confirmationPrecertification form includes explicit checkboxes confirming proposed dosing does not exceed 0.5 mcg/kg per HD treatment and does not exceed three doses/week

Precertification and Provider Requirements

Prior Authorization

Precertification submission required via Aetna form

Submit precertification using Aetna's Korsuva (difelikefalin) Medication Precertification Request form. Send submissions to Aetna Precertification Notification via phone or fax; use the Medicare request form for Medicare Advantage Part B submissions.

Aetna Precertification Notification phone: 1-866-752-7021 (TTY: 711)
Aetna Precertification Notification fax: 1-888-267-3277
For Medicare Advantage Part B, use the Medicare request form

Step Therapy

Document prior therapy trials/failures

Document prior trials and failures of other pruritus therapies on the clinical checklist—responses are required about whether the patient has tried and failed listed treatments or has contraindications to them.

Checkbox documents trials/failures of antihistamines

Background

Korsuva (difelikefalin injection) is indicated on the precertification form for treatment of pruritus, including pruritus associated with chronic kidney disease in patients undergoing dialysis. The form anchors clinical review to baseline and follow‑up severity scoring (for example, the Worst Itching Intensity Numerical Rating Scale) and documents dialysis status and prior treatment history to support both initiation and continuation decisions.

Definitions and Scoring Tools

WI‑NRS — Baseline and follow‑up severity/response scoring

Tool nameWorst Itching Intensity Numerical Rating Scale (WI‑NRS)

Use on formReferenced for baseline severity documentation to support CKD‑associated pruritus (e.g., initial assessment)

Use for continuationReferenced for response assessment; continuation example is ≥4‑point improvement from baseline on WI‑NRS

Alternate scales notedForm also lists visual analog scale (VAS)/numeric rating scale (NRS) as examples for baseline scoring