CurrentAetnaPolicy N/A

Epoprostenol (Flolan, Veletri) Medication Precertification Request

This document is Aetna's precertification request form for initiation or continuation of therapy with epoprostenol (Flolan or Veletri) and governs what clinical and administrative information must be submitted for coverage review.

Policy Summary

PayerAetna

PolicyEpoprostenol (Flolan, Veletri) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed and legible precertification form with required clinical documentation via Aetna Precertification Notification (phone 1-866-752-7021 or fax 1-888-267-3277).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2pages in the form

3product names listed

1-866-752-7021precert phone/fax

Coverage Criteria

Precertification clinical criteria

Covered when documentation provided and clinical criteria are met per precertification form.

Provider and Prescriber: Requested medication must be prescribed by or in consultation with a pulmonologist or cardiologist.

Form asks provider to confirm pulmonologist or cardiologist involvement (Yes/No).

Diagnosis of pulmonary arterial hypertension (PAH) indicated and WHO classification provided.

Form requires selection of WHO pulmonary hypertension classification and confirmation of PAH diagnosis.

Hemodynamic Confirmation: Diagnosis confirmed by right heart catheterization with pretreatment values documented (mPAP, PCWP, PVR).

Form provides selectable pretreatment ranges: mPAP (<=20 mmHg or >20 mmHg); PCWP (<=15 mmHg or >15 mmHg); PVR (<3 Wood units, >=3 Wood units, or No).

Policy Summary

PayerAetna

PolicyEpoprostenol (Flolan, Veletri) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed and legible precertification form with required clinical documentation via Aetna Precertification Notification (phone 1-866-752-7021 or fax 1-888-267-3277).

SourceLink

On This Page

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Coding

Administration CPT codes (placeholders)CPT

Administration code(s) (CPT):

Place to list CPT administration codes as applicable

Diagnosis codesICD-10

Primary ICD Code:

Place to list primary diagnosis ICD-10 code

inv-06: Pulmonary vascular resistance (PVR) — options provided

Pulmonary vascular resistance (PVR) optionsNo / <3 Wood units / ≥3 Wood units (select the appropriate pretreatment value from the form)

Clinical usePVR is required as part of hemodynamic confirmation of PAH by right heart catheterization.

DocumentationRecord pretreatment PVR result on the precertification form to support initiation requests.

inv-07: Mean pulmonary arterial pressure (mPAP) — options provided

Mean pulmonary arterial pressure (mPAP) options≤ 20 mmHg or > 20 mmHg (select the pretreatment mPAP at rest on the form)

Clinical rolemPAP is required for hemodynamic confirmation of pulmonary arterial hypertension (PAH).

DocumentationIndicate the pretreatment mPAP result on the precertification form for initiation requests.

inv-08: Pulmonary capillary wedge pressure (PCWP) — options provided

Pulmonary capillary wedge pressure (PCWP) options≤ 15 mmHg or > 15 mmHg (select the pretreatment PCWP on the form)

Clinical rolePCWP is collected to help differentiate pre- vs post-capillary pulmonary hypertension during right heart catheterization.

DocumentationIndicate the pretreatment PCWP result on the precertification form to support diagnosis confirmation.

Provider Actions / Requirements

Prior Authorization

Prior Authorization Required

Precertification is required for this medication. Requests must be submitted via the Aetna Precertification Notification phone or fax (see contact numbers).

Phone: 1-866-752-7021
FAX: 1-888-267-3277
For Medicare Advantage Part B: Use Medicare Request Form

Documentation Required

Administration / Dispensing Specification

Indicate the place of administration and specify the dispensing provider on the precertification form. Options must include self-administered, physician office, outpatient infusion center, home infusion center, or other as applicable. If administration occurs in a facility or via infusion services, include administration CPT code(s) on the form.

Place of Administration: Self-administered; Physician's Office; Outpatient Infusion Center; Home Infusion Center; Other
Include Administration code(s) (CPT) when applicable
Dispensing Provider/Pharmacy: Physician's Office; Retail Pharmacy; Specialty Pharmacy; Other

Documentation Required

Required Documentation for Precertification

Complete and legible precertification form fields are required for review. Ensure all patient demographics, insurance information, prescriber and dispensing provider details, product requested, dose/frequency, diagnosis (ICD code), and required clinical documentation (see initiation and continuation sections) are provided.

Patient demographics and contact information
Prescriber details (name, specialty, NPI, license, contact)
Dispensing provider/pharmacy details (name, address, TIN/PIN, phone, fax)
Product, dose, frequency and diagnosis (primary ICD code)
Required clinical documentation: WHO classification, confirmation of PAH, right heart catheterization results, hemodynamics (mPAP, PCWP, PVR), echocardiogram results, and continuation benefit documentation where applicable

Denial Risk

Fraud / False Information

By signing the request, the requester acknowledges that submitting materially false information or concealing material information may result in denial of the request and may subject the submitter to fraud investigation and civil/criminal penalties.

Request Completed By (Signature Required)
Fraudulent insurance act warning as stated on the form

Background

Epoprostenol (Flolan, Veletri) is requested for management of pulmonary arterial hypertension (PAH). The form requires the World Health Organization (WHO) classification of pulmonary hypertension and asks whether the patient has a diagnosis of PAH and whether that diagnosis has been confirmed by right heart catheterization. It also requests pretreatment hemodynamic values — mean pulmonary arterial pressure (mPAP) (≤ 20 mmHg or > 20 mmHg), pulmonary capillary wedge pressure (PCWP) (≤ 15 mmHg or > 15 mmHg), and pulmonary vascular resistance (PVR) (< 3 Wood units, ≥ 3 Wood units, or No) — and whether a Doppler echocardiogram has been performed. Precertification requests must be completed in full so these elements are available to support medical necessity for initiation or continuation of epoprostenol therapy.

Definitions and Assessment Elements

inv-14: mPAP, PCWP, PVR and WHO classification — Pulmonary arterial hypertension (PAH) assessment elements

Required hemodynamic elementsDocument pretreatment mPAP, PCWP, and PVR from right heart catheterization on the precertification form.

WHO classificationIndicate the WHO classification (1–5) of pulmonary hypertension on the form to support PAH assessment.

PAH diagnosis confirmationConfirm whether the patient has a diagnosis of pulmonary arterial hypertension (PAH) and whether diagnosis was confirmed by right heart catheterization.

Additional testingIndicate whether a Doppler echocardiogram has been performed to diagnose PAH.