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Korsuva (difelikefalin injection) Medication Precertification Request — Coverage Criteria
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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.
No material clinical or coverage changes in this revision.
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.
Modeled from the form's required clinical checklist
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 code(s) (CPT) | Placeholder on form for relevant CPT administration codes |
Precertification and Provider Requirements
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
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
- Checkbox documents trials/failures of gabapentin or pregabalin
- Checkbox documents trials/failures of topical emollients/analgesics
- Checkbox for contraindications to these therapies
Provide required patient, prescriber, dispensing, dosing, and diagnosis details
Include complete patient demographics, weight and height, prescriber and dispensing provider details, requested Korsuva dose and frequency, and diagnosis coding along with the completed clinical checklist fields.
- Patient name, DOB, contact information, current weight and height
- Prescriber name, credentials, specialty, phone, fax, NPI and state license
- Dispensing provider/place of administration selection
- Requested Korsuva dose and frequency (as entered on product information section)
- Primary and any secondary ICD codes
- Completed clinical checklist including diagnosis, dialysis status, baseline WI-NRS and prior therapies
Incomplete clinical documentation may cause denial or delay
Incomplete or missing required clinical checklist items may result in denial or the need for additional information and delay of the precertification decision.
- Absence of documented diagnosis of pruritus or CKD-associated pruritus with baseline scoring
- Missing dialysis status or prescriber specialty checkbox
- Unanswered items about prior therapies, contraindications, or dosing limits
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
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