CurrentAetnaPolicy N/A

Rylaze (asparaginase erwinia chrysanthemi [recombinant]-rywn) Precertification Request Coverage Criteria

Precertification form and requirements for requesting coverage of Rylaze for Aetna members; used by prescribers/dispensing providers to request initiation or continuation of therapy for patients with acute lymphoblastic leukemia (ALL) or lymphoblastic lymphoma (LBL).

Policy Summary

PayerAetna

PolicyRylaze precertification request - coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit the completed precertification request form to Aetna via phone or fax prior to treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page count

2indications listed

1drug covered

3request types

Coverage Criteria for Rylaze

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Core requirements: Patient has diagnosis of acute lymphoblastic leukemia (ALL) or lymphoblastic lymphoma (LBL) AND request specifies Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) with dose and frequency AND provided prescriber, patient, insurance, and dispensing provider information

Form requires completion of these fields for precertification.

Initiation-specific: For initiation requests, documentation that the patient has developed hypersensitivity to E. coli-derived asparaginase (e.g., pegaspargase)

Checked as required clinical documentation for initiation.

Continuation-specific: For continuation requests, documentation about unacceptable toxicity or disease progression while on current regimen must be provided

Form includes a question for continuation requests regarding toxicity or progression.

Initiation Therapy Documentation

Initiation therapy documentation

Initiation requests require documentation of prior hypersensitivity if used as rationale.

Initiation criteria: Diagnosis of ALL or LBL AND documentation that patient developed hypersensitivity to E. coli-derived asparaginase (e.g., pegaspargase) if substitution is being requested

Form explicitly asks whether hypersensitivity to E. coli-derived asparaginase has occurred.

Continuation Therapy Documentation

Continuation therapy documentation

For continuation requests provide clinical documentation addressing tolerance and disease status.

Continuation documentation: Date of last treatment AND evidence addressing unacceptable toxicity or disease progression while on current regimen

Form contains checkbox and field for continuation and asks about toxicity/progression.

Requested Codes

Administration CPT Codes (requested)CPT

Administration code(s) (CPT)

Administration CPT codes to be provided by requestor as indicated on the form

Diagnosis ICD Codes (requested)ICD-10

Primary ICD Code	Primary diagnosis ICD code to be provided (example diagnoses: acute lymphoblastic leukemia, lymphoblastic lymphoma)
Secondary ICD Code	Secondary diagnosis ICD code to be provided
Other ICD Code	Any other applicable ICD codes

Provider Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Providers must submit this completed precertification request form to Aetna prior to treatment. Submit via phone or fax using the Aetna Precertification Notification contact numbers below. Incomplete or illegible submissions may delay review; Aetna may request additional information or clarification.

Aetna Precertification Notification Phone: 1-866-752-7021
Aetna Precertification Notification FAX: 1-888-267-3277
Medicare Advantage Part B Phone: 1-866-503-0857
Medicare Advantage Part B FAX: 1-844-268-7263

Documentation Required

Documentation Required for Precertification

Completed precertification requests must include the full set of patient, insurance, prescriber, dispensing/provider, product, diagnosis, and clinical information as indicated on the form. All fields must be completed and legible for precertification review. The plan may request additional information if needed.

Patient information: name, DOB, contact information, weight, height, allergies
Insurance information: Aetna Member ID, group #, other coverage details and IDs, Medicare/Medicaid indicators
Prescriber information: name, credentials, address, phone, fax, state license #, NPI, DEA, specialty
Dispensing/provider information: place of administration, administration site, dispensing provider/pharmacy name, address, phone, fax, TIN/PIN, administration CPT codes
Product information: requested drug (Rylaze), dose, frequency
Diagnosis information: primary and any secondary ICD-10 codes
Clinical documentation: indication of ALL or LBL, documentation of hypersensitivity to E. coli–derived asparaginase for initiation requests, whether drug will be used with multi-agent chemotherapy, and for continuation requests evidence of unacceptable toxicity or disease progression as applicable
Signature and date: request completed by (signature required) and date

Step Therapy

Step / Sequence Information

For initiation requests, the form requires documentation that the patient has developed hypersensitivity to E. coli–derived asparaginase (for example, pegaspargase). For continuation requests, provide documentation regarding response, toxicity, or disease progression on the current regimen. Indicate whether the requested drug will be used in conjunction with multi-agent chemotherapy.

Initiation: confirm hypersensitivity to E. coli–derived asparaginase (e.g., pegaspargase) and provide supporting clinical notes
Continuation: provide evidence of clinical status — unacceptable toxicity or disease progression while on current regimen
Specify whether therapy is start of treatment (include start date) or continuation (include date of last treatment)

Denial Risk

Incomplete Submission Risk

Incomplete or illegible fields may prevent precertification review and can result in delays or denial. Ensure all required sections and supporting documentation are included at time of submission. Aetna may contact the provider for missing information.

All fields must be completed and legible
Aetna may request additional information or clarification if needed
Failure to provide required documentation may delay review or result in denial

Question	Response options / Documentation required
Has the patient developed hypersensitivity to E. coli-derived asparaginase (e.g., pegaspargase)?
- Yes / No checkboxes. For initiation requests, clinical documentation of hypersensitivity must be provided if 'Yes' is selected.

Place of Administration

Note

Specify place of administration on the form

The form requires specification of the place of administration for the requested drug; indicate whether administration is self-administered, in a physician's office, outpatient infusion center, or home infusion center.

Place of Administration options: Self-administered; Physician's Office; Outpatient Infusion Center; Home Infusion Center
Provide phone and center/agency name for the administration site as requested on the form

Key Definitions

Hypersensitivity to E. coli-derived asparaginase — definition and form requirements

TermHypersensitivity to E. coli-derived asparaginase

DefinitionClinical reaction to E. coli-derived asparaginase formulations (e.g., pegaspargase) noted on the form as a reason to request Rylaze for initiation.

Form question locationG. Clinical Information — For Initiation Requests: 'Has the patient developed hypersensitivity to E. coli-derived asparaginase (e.g., pegaspargase)?'

Required when used as rationale for initiationIf substitution with Rylaze is requested for initiation, clinical documentation of hypersensitivity to E. coli-derived asparaginase must be provided.

Examples referencedThe form explicitly cites pegaspargase as an example of an E. coli-derived asparaginase.

Background

Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) is an asparaginase formulation used in treatment regimens for acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL). The Aetna precertification request form captures whether the request is for start of treatment or continuation of therapy, and requires the requested product, dose and frequency, and confirmation of diagnosis to support medical review.

For initiation requests, the form specifically requires documentation that the patient has developed hypersensitivity to E. coli–derived asparaginase (e.g., pegaspargase) when substitution with Rylaze is the rationale. For continuation requests, the form requests documentation addressing unacceptable toxicity or disease progression on the current regimen. All required clinical fields in section G must be completed in their entirety for precertification review.

All fields on the form must be completed and legible. Providers must submit the completed precertification request to Aetna via phone or fax prior to treatment using the contact numbers provided on the form. The plan may request additional information or clarification as needed to evaluate the request, and incomplete or illegible submissions may affect authorization.