CurrentAetnaPolicy N/A

Ocrevus (ocrelizumab) Precertification Request — Coverage Criteria

Precertification request form and requirements for Ocrevus (ocrelizumab) for Aetna members; governs documentation and prior authorization for initiation and continuation of therapy across outpatient settings and dispensing options.

Policy Summary

PayerAetna

PolicyOcrevus (ocrelizumab) Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed Aetna Precertification Notification (phone or fax) with full clinical documentation including MS type, start vs continuation, prior/concomitant MS agents, and justification for outpatient hospital setting when requested.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2page form length

1-866-752-7021precertification phone

1-888-267-3277fax for precertification

Coverage and Medical Necessity Criteria

Precertification coverage criteria

Covered when ALL of the following are met

Form completion: Precertification request form fully completed with patient, insurance, prescriber, dispensing/administration, and product information

Fields include start vs continuation of therapy, dose, frequency, primary and other ICD codes

Clinical information: Required clinical information provided: type of MS, whether therapy is initiation or continuation, documentation of any adverse events to the product, and whether the patient is taking the requested medication with any other disease-modifying MS agent

Form includes checkboxes for MS subtype, concomitant MS agents, and prescriber neurologist involvement; continuation requests must indicate disease stability or improvement

Administration setting justification: If an outpatient hospital setting is requested, medical justification must be provided (e.g., prior severe or refractory infusion reaction, severe venous access issues requiring special interventions, significant behavioral/physical/cognitive impairment without caregiver, or medical instability such as cardiovascular, respiratory, or renal conditions)

Policy Summary

PayerAetna

PolicyOcrevus (ocrelizumab) Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Descriptive fields on form request details of adverse events and specific organ/system conditions

The precertification form does not list explicit exclusions for Ocrevus requests. However, the form requires comprehensive clinical documentation for every request, including whether the infusion is being requested in an outpatient hospital setting, prior adverse reactions, venous access issues, behavioral or cognitive impairment, and medical instability. Requests that do not include these required fields or adequate justification for the requested administration setting may be returned for additional information or excluded from coverage until sufficient documentation is provided.

The form does not identify specific clinical scenarios that are automatically considered not medically necessary. Instead, denials may result when the submitted clinical documentation does not support the requested therapy or administration setting—for example, missing information about treatment status (new versus continuation), history of adverse events or inability to manage such events outside a hospital setting, severe venous access issues, or details about medical or behavioral instability.

Requested Codes and Billing

Requested codes / placeholdersmixed

Administration code(s) (CPT):	Placeholder for provider to list applicable CPT administration codes
Primary ICD Code:	Primary diagnosis ICD code for the request
Other ICD Code:	Additional diagnosis ICD code

Requested codes / placeholdersmixed

Administration code(s) (CPT):	Placeholder for provider to list applicable CPT administration codes
Primary ICD Code:	Primary diagnosis ICD code for the request
Other ICD Code:	Additional diagnosis ICD code

Requested codes / placeholdersmixed

Administration code(s) (CPT):	Placeholder for provider to list applicable CPT administration codes
Primary ICD Code:	Primary diagnosis ICD code for the request
Other ICD Code:	Additional diagnosis ICD code

Precertification, Submission & Documentation Requirements

Prior Authorization

Precertification required — Prior authorization required

Prior authorization is required. Submit precertification requests to Aetna using the Aetna Precertification Notification (phone or fax) or the Medicare Request Form for Medicare Advantage Part B members.

All fields on the Ocrevus (ocrelizumab) Medication Precertification Request must be completed and all pages returned for review.
Submit via Aetna Precertification Notification: Phone 1-866-752-7021 (TTY: 711) or Fax 1-888-267-3277.

Documentation Required

Concomitant therapy documentation

The precertification form asks whether the patient is taking Ocrevus concurrently with any other disease-modifying multiple sclerosis (MS) agent. Providers must indicate if the patient is on concomitant DMT(s) and identify them. (Note: Ampyra and Nuedexta are not disease-modifying agents.)

Question on form: "Is the patient taking the requested medication with any other disease modifying multiple sclerosis (MS) agent?" — mark Yes or No and list agents if Yes.
Form clarifies Ampyra and Nuedexta are not disease-modifying.

Documentation Required

Required submission elements

Completed precertification form must include required submission elements: patient demographics, insurance information, prescriber and administering/dispensing information, product details (Ocrevus dose and frequency), primary and other ICD codes, and indication of start/continuation dates. Include documentation of clinical information requested in Section G (MS diagnosis type, continuation therapy status, adverse event history, infusion setting, medical instability, and behavioral/venous access issues) as applicable.

Required: Patient name and demographics; insurance information; precertification requested by, phone, fax.
Required: Prescriber information and whether prescribed by or in consultation with a neurologist.
Required: Product information — Ocrevus (ocrelizumab), dose, frequency, primary and other ICD codes.
Required: Indicate whether start of treatment (start date) or continuation of therapy (date of last treatment).
Required: For continuation requests, document whether patient is experiencing disease stability or improvement while on therapy.
Required: Documentation of outpatient infusion setting, history of adverse events with product and response to interventions, severe venous access issues, behavioral/physical/cognitive impairments affecting infusion safety, and any medical instability (cardiovascular, respiratory, renal, other).

Denial Risk

Incomplete clinical information may lead to denial

Incomplete clinical information may lead to denial. Missing documentation for outpatient infusion setting justification, adverse event history and management, or medical instability/behavioral/venous access details can result in non-approval.

Ensure all sections of the precertification form (including Section G clinical information) are completed in their entirety.
Provide clear descriptions for any "Yes" responses related to adverse events, behavioral issues, venous access problems, or medical instability.

Clinical Background

Background: Ocrevus (ocrelizumab) is an infused monoclonal antibody used to treat multiple sclerosis. The precertification form captures key clinical details required to determine appropriateness for initiation or continuation of therapy and to justify the chosen administration setting. Required clinical fields include whether the request is for continuation or new therapy, history of adverse events to the product, presence of severe venous access problems, significant behavioral or cognitive impairment affecting infusion safety, and whether the patient is medically unstable (cardiovascular, respiratory, renal, or other).

Key Definitions

Relapsing forms of multiple sclerosis — relapsing-remitting and secondary progressive with relapses captured on the form

DefinitionRelapsing forms of multiple sclerosis — includes relapsing-remitting and secondary progressive disease for those who continue to experience relapse as listed on the form.

Form captureThe precertification form includes a checkbox option: 'Relapsing forms of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse)'.

Use in documentationMust be selected on the clinical information section of the Ocrevus precertification request when applicable.

Relevance to continuation requestsWhen selected for continuation requests, the form also requires documentation of disease stability or improvement while receiving the medication.

Primary-progressive multiple sclerosis — primary-progressive MS option captured on the form

DefinitionPrimary-progressive multiple sclerosis — listed as a distinct diagnosis option on the precertification form.

Form captureThe clinical information section includes a checkbox: 'Primary-progressive multiple sclerosis'.

Use in documentationSelect this option when the patient’s diagnosis is primary-progressive MS to clearly indicate disease subtype for the request.

Impact on reviewChoice of MS subtype (including primary-progressive) is required information for all precertification requests and informs the clinical review.