Macugen (pegaptanib sodium) precertification request form
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Precertification form and instructions for requesting authorization of Macugen (pegaptanib sodium) injections for members; used by prescribers and dispensing providers to request start or continuation of therapy.
No material clinical or coverage changes in this revision.
Coverage Criteria and Form Notes
Initiation and Continuation Criteria (form-based)
Coverage requests are processed when required form fields and clinical information for initiation or continuation are provided.
Form requires clinical documentation for all initiation requests
Form asks explicitly about positive clinical response
The form itself does not enumerate explicit coverage criteria; rather, it functions as a precertification request template that requires completion of specified fields and clinical information to support initiation or continuation of Macugen (pegaptanib) therapy.
The form does not contain an explicit statement labeling any conditions or uses as "not medically necessary." It focuses on collecting required information and includes an acknowledgement regarding truthful submission and the plan’s ability to request additional information.
Billing and Diagnosis Codes
| Administration code(s) (CPT) | Administration CPT code(s) – requested to be provided on form |
| Primary ICD Code | Primary diagnosis ICD code (to be specified by provider) |
Precertification, Documentation, and Provider Responsibilities
Prior Authorization Required
Precertification is required for Macugen (pegaptanib sodium injection). Submit precertification requests using the Macugen precertification form. Aetna Precertification Notification: Phone 1-866-752-7021, FAX 1-888-267-3277. For Medicare Advantage Part B: Phone 1-866-503-0857, FAX 1-844-268-7263.
- Use the Macugen precertification form to request prior authorization.
- Aetna Precertification Notification: Phone 1-866-752-7021 • FAX 1-888-267-3277
- Medicare Advantage Part B precertification: Phone 1-866-503-0857 • FAX 1-844-268-7263
Continuation Response Requirement
For continuation (renewal) requests, the form must document whether the patient has demonstrated a positive clinical response to therapy. Positive response examples include improvement or maintenance in best corrected visual acuity (BCVA) or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss.
- Continuation requests must indicate date of last treatment.
- Continuation question on form: Has the patient demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or reduction in rate of vision decline)? — Yes / No
Required Documentation
Complete clinical and administrative documentation is required for all precertification requests. The precertification form requests the following minimum information: patient identifiers and start/continuation dates; prescriber and contact information; dispensing provider and product/dose details; primary and any additional ICD diagnosis codes; and for clinical review, diagnosis selection and clinical evidence of response for continuation requests.
- Patient: identifiers, start of treatment date or date of last treatment for continuation requests.
- Prescriber: name, phone, fax, signature and date on the acknowledgement.
- Dispensing provider / product: Macugen (pegaptanib sodium injection), dose, and directions for use.
- Diagnosis: primary ICD code (and other ICD codes as applicable).
- Clinical documentation: selected diagnosis (e.g., neovascular (wet) AMD or other) and, for continuation, documentation of positive clinical response (improvement or maintenance in BCVA/visual field or reduction in vision decline).
Incomplete or False Information
Any person who knowingly submits a request with the intent to defraud by providing materially false information or concealing material information may be subject to criminal and civil penalties. The plan may request additional information or clarification if needed to evaluate requests.
- Knowingly providing false or misleading information may result in criminal and civil penalties.
- Aetna may request additional information or clarification to complete evaluation of the precertification request.
Key Definitions
Background
Pegaptanib (Macugen) is an intravitreal therapy used to treat neovascular (wet) age-related macular degeneration. This precertification request form is intended to collect patient, prescriber, dispensing provider, product/dose and clinical information needed to request authorization for initiation or continuation of Macugen injections, and to document attestation and allow the plan to request additional information as necessary.
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