CurrentAetnaPolicy N/A

Macugen (pegaptanib sodium) precertification request form

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.

Policy Summary

PayerAetna

PolicyMacugen (pegaptanib sodium) precertification request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Macugen precertification form with required patient, clinical, product, dosing and ICD diagnosis information for start or continuation requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page count

1-888-267-3277precert fax

1-866-752-7021precert phone

Medicare Advantage Part Bcontact line

Coverage Criteria and Form Notes

Initiation Requests: For initiation: provider must select diagnosis (Neovascular (wet) age related macular degeneration or other) and supply product information, dosing, patient and insurance details.

Form requires clinical documentation for all initiation requests

Continuation Requests: For continuation: provider must document date of last treatment and indicate that the patient has demonstrated a positive clinical response (improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or risk of more severe vision loss).

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 codesCPT

Administration code(s) (CPT)

Administration CPT code(s) – requested to be provided on form

Diagnosis codesICD-10

Primary ICD Code

Primary diagnosis ICD code (to be specified by provider)

Precertification, Documentation, and Provider Responsibilities

Prior Authorization

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

Documentation Required

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

Documentation Required

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).

Denial Risk

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

Positive clinical response — definition and use

DefinitionPositive clinical response: 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.

Clinical contextRequired documentation for continuation requests: provider must indicate whether the patient has demonstrated a positive clinical response to therapy.

Assessment examplesExamples of a positive response include measurable improvement or stabilization of BCVA, preservation or stabilization of visual field, or slowed progression of vision loss over time.

Action (most actionable)For continuation authorization, mark ‘Yes’ on the form indicating the patient demonstrated a positive clinical response (improvement/maintenance in BCVA or visual field, or reduced rate of vision decline).

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.