CurrentAetnaPolicy N/A

ELAHERE (mirvetuximab soravtansine-gynx) precertification request form coverage criteria

Precertification request form and required information for Aetna coverage review of ELAHERE (mirvetuximab soravtansine-gynx) for oncology indications; used by prescribing and dispensing providers to request start or continuation of therapy.

Policy Summary

PayerAetna

PolicyELAHERE (mirvetuximab soravtansine-gynx) precertification request form coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed precertification request form with required clinical and administrative fields for start or continuation of ELAHERE therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page

ELAHEREbrand

mirvetuximabgeneric

3indications

1-866-752-7021precert phone

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Precertification submission

Coverage review is performed when all required clinical and administrative fields are completed; the form requests specific clinical elements used to determine medical necessity.

Precertification submission requirements: Form fully completed with patient demographics, insurance, prescriber info, dispensing/provider info, product info (dose and frequency), primary and other ICD codes, and required clinical information for initiation or continuation

Provider signature required on acknowledgment

Initiation Therapy

For initiation requests, the following clinical items are collected:

Initiation clinical data: Diagnosis selected from epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer, or other; folate receptor-alpha status indicated (Yes/No/Unknown); platinum-resistance status indicated (Yes/No); has the patient received at least one prior systemic therapy (Yes/No); requested regimen specified (single agent, in combination with bevacizumab, or other)

Clinical documentation required for all initiation requests

Continuation Therapy

For continuation requests, the following clinical items are collected:

Continuation clinical data: Date of last treatment provided; indicate whether there is evidence of unacceptable toxicity or disease progression while on the current regimen (Yes/No); include updated clinical documentation

Clinical documentation required for all continuation requests

The precertification form does not enumerate explicit covered or excluded diagnoses. The form asks the provider to supply a primary ICD code and any secondary/other ICD codes, and it permits selection of an "Other" diagnosis option on the product/diagnosis sections, but it does not list which diagnoses are covered or excluded.

The acknowledgement section includes a legal warning that knowingly submitting materially false or concealed information to obtain coverage is a fraudulent insurance act and may lead to criminal and civil penalties. The form also states that the plan may request additional information or clarification as needed to evaluate the request, and it provides Aetna precertification contact details for follow-up.

What the Provider Must Do

Prior Authorization

Precertification request required — Elahere

A completed precertification request form is required for start or continuation of treatment with Elahere. All fields on the form must be completed and legible for precertification review; incomplete or illegible submissions may result in denial or requests for clarification.

Start of treatment or Continuation of therapy must be indicated with dates.
Use Aetna Precertification Notification: Phone 1-866-752-7021 (TTY: 711); Fax 1-888-267-3277.

Note

Clinical step information collected

The form collects required clinical information for initiation and continuation requests. For initiation it requires diagnosis (epithelial ovarian, fallopian tube, primary peritoneal, or other), requested regimen (single agent, with bevacizumab, other), folate receptor-alpha status, platinum-resistance status, and whether the patient has received at least one prior systemic therapy. For continuation it requires documentation of response and whether there is unacceptable toxicity or disease progression while on the current regimen.

Diagnosis selection (e.g., epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer).
Requested regimen and combination details (including bevacizumab).
Folate receptor-alpha status: Yes/No/Unknown.
Platinum-resistant disease: Yes/No.
Prior systemic therapy: Yes/No.
For continuation: evidence of unacceptable toxicity or disease progression while on current regimen.

Documentation Required

Required documentation for review

Complete clinical information and supporting documentation must be provided for initiation and continuation requests. Include patient identifiers, diagnosis, prior therapies, platinum-resistance status, folate receptor-alpha testing results (if available), proposed regimen and dosing, dates of prior and last treatments, and clinician signature and date. The plan may request additional information or clarification if needed to evaluate the request.

Patient demographics and contact information (name, DOB, address, phone, weight/height, allergies).
Prescriber information including license, NPI, specialty, and contact details.
Product information: Elahere dose and frequency.
Documentation of prior systemic therapies and dates.
Folate receptor-alpha test results and platinum-resistance documentation.
For continuation: records demonstrating treatment response, toxicity, or progression.
Signature of person completing the request and date.

Denial Risk

Incomplete submission risk

Failure to provide complete and legible fields or requested additional information may result in denial of the precertification request or issuance of a clarification request. Ensure all required fields are filled and supporting records are attached to avoid processing delays.

Incomplete or illegible submissions risk denial or need for additional information.
Attach supporting clinical records and test results to prevent requests for clarification.

Initial Therapy — Coverage Conditions

Initiation requests

Initial therapy requests must include the following clinical elements:

Initial therapy requirements: Select diagnosis (epithelial ovarian, fallopian tube, or primary peritoneal cancer, or Other); document folate receptor-alpha status (Yes/No/Unknown); document platinum-resistant status (Yes/No); state prior systemic therapy history (has received at least one prior systemic therapy: Yes/No); specify requested regimen (single agent or in combination with bevacizumab, or Other)

Clinical documentation required for all initiation requests

Requirement	Form field / collected response
Documentation that the patient has received at least one prior systemic therapy
Has the patient received at least one prior systemic therapy? — checkbox: Yes / No
Documentation of platinum-resistance status
Does the patient have platinum-resistant disease? — checkbox: Yes / No

Key Definitions and Biomarker Status

Platinum-resistant disease

DefinitionPlatinum-resistant disease — clinical status queried on the form to inform coverage decisions; the form asks ‘Does the patient have platinum-resistant disease?’ with options Yes or No.

PurposeCollected as part of initiation and step-therapy assessment to determine prior-line therapy response and eligibility considerations for Elahere (mirvetuximab soravtansine-gynx).

When to reportRequested on the precertification form for all initiation requests and used in coverage review; providers must indicate Yes or No.

Folate receptor-alpha positive

DefinitionFolate receptor-alpha positive — tumor biomarker status requested on the form; response options are Unknown, Yes, or No.

PurposeCollected to identify likely target expression for mirvetuximab soravtansine-gynx therapy and to support medical necessity determinations for initiation requests.

When to reportRequired field on the initiation section of the precertification form; providers must select Unknown, Yes, or No.

Policy Summary

PayerAetna

PolicyELAHERE (mirvetuximab soravtansine-gynx) precertification request form coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed precertification request form with required clinical and administrative fields for start or continuation of ELAHERE therapy.

SourceLink

On This Page

Primary ICD Code	Primary diagnosis ICD-10 code to be supplied by provider
Secondary ICD Code	Secondary diagnosis ICD-10 code to be supplied by provider
Other ICD Code	Other applicable ICD-10 codes

OpenPayer

ELAHERE (mirvetuximab soravtansine-gynx) precertification request form coverage criteria

Coverage Criteria / Form Requirements

Billing and Diagnosis Codes

What the Provider Must Do

Initial Therapy — Coverage Conditions

Continuation Therapy — Ongoing Treatment Conditions

Prior Therapy / Step Requirements

Place of Administration

Key Definitions and Biomarker Status

Background — Drug and Indication