CurrentAetnaPolicy N/A

Levoleucovorin (Fusilev ® , Khapzory TM ) Injectable Medication Precertification Request

Form used by Aetna to request precertification (prior authorization) for levoleucovorin injectable products (Fusilev, Khapzory) for start or continuation of therapy; collects patient, insurer, prescriber, dispensing, product, diagnosis, and clinical justification details required for review.

Policy Summary

PayerAetna

PolicyLevoleucovorin (Fusilev ® , Khapzory TM ) Injectable Medication Precertification Request

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete and submit this precertification request form with all required fields and clinical documentation to Aetna via phone or fax for review prior to administration or dispensing of levoleucovorin injectable products.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

1Form Purpose (precertification request)

2Product Options (Fusilev, Khapzory)

3Clinical Use Options Listed

Document overview

This Aetna precertification (prior authorization) request form is used to request approval for levoleucovorin injectable products (Fusilev, Khapzory). It gathers patient, payer/insurance, prescriber, dispensing/provider, product, diagnosis (ICD), and clinical rationale information necessary for Aetna to evaluate coverage and determine precertification.

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Requested coding and administration details

ICD-10 Diagnosis Codes (Requested by form)ICD-10

No codes listed

Administration CPT Codes (to be provided by requester)CPT

No codes listed

The form asks for the place of administration (self-administered, physician’s office, outpatient infusion center, home infusion center) and requests any applicable administration CPT code(s). It also collects the dispensing provider/pharmacy details and the patient’s selected dispensing option (physician’s office, retail pharmacy, specialty pharmacy, or other).

Provider requirements and submission instructions

Prior Authorization

Precertification required

Providers must complete and submit this precertification request form with all required fields and clinical documentation to Aetna via phone or fax for review prior to administration or dispensing of levoleucovorin injectable products.

Documentation Required

Clinical justification documentation

Include indication (ICD code), intended use (rescue, overdose, combination therapy, or other), dosing, frequency, start/continuation dates, and for Khapzory requests, documentation of ineffective response, intolerance, or contraindication to Fusilev or generic equivalent.

Billing Rule

Provide administration and dispensing details

Submit place of administration, administration CPT codes if applicable, dispensing provider/pharmacy information, and selected dispensing option (office/retail/specialty/other).

Documentation Required

Signature attestation

Request must be completed and signed; signer acknowledges fraud warning and that plan may request additional information for evaluation.

Background & definitions

This precertification notification form is used by Aetna to request prior authorization for levoleucovorin injectable products (brand examples: Fusilev, Khapzory). It collects key information — patient demographics and weight/height, insurance/member details, prescriber credentials and contact data, dispensing/provider and administration details, requested product and dosing, primary and secondary ICD-10 diagnosis codes, and required clinical justification — to support Aetna’s review and coverage determination.

LevoleucovorinActive drug (brand examples: Fusilev, Khapzory) for rescue after methotrexate, folate antagonist overdose, or as leucovorin rescue with 5-FU regimens.