CurrentAetnaPolicy N/A

Ventavis (iloprost inhalation solution) precertification for pulmonary hypertension

Precertification request form and clinical criteria checklist for initiation or continuation of Ventavis (iloprost inhalation solution) for members receiving Aetna coverage. Intended for prescribing providers (pulmonologists/cardiologists) and dispensing providers to supply required clinical and administrative information to obtain authorization.

Policy Summary

PayerAetna

PolicyVentavis (iloprost inhalation solution) precertification for pulmonary hypertension

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit the completed Ventavis precertification form with required clinical and administrative data to Aetna for review prior to therapy initiation or for continuation requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initiation & continuationRequest types supported

RHCDiagnostic confirmation requested

WHORequires WHO PH classification (1-5)

SpecialistMust be prescribed by/with pulmonologist or cardiologist

Authorization Criteria for Ventavis (iloprost) - Initiation & Continuation

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Precertification submission requirements

Authorization will be evaluated when required clinical and administrative information is provided. The form requests the following items:

ALL of the following

Completed patient demographic and insurance information (member ID, group, other coverage if applicable)
Prescriber information including licensure, NPI, specialty (MD/DO/NP/PA) and indication whether prescriber is a pulmonologist or cardiologist
Dispensing/provider administration information including place of administration and CPT administration codes if applicable
Product information: requested Ventavis dose and dosing frequency
Primary ICD diagnosis code and any additional diagnosis codes

Clinical criteria for initiation requests

For initiation of Ventavis, ALL of the following clinical items are requested on the form:

ALL of the following

Is the medication prescribed by or in consultation with a pulmonologist or cardiologist?
Form includes a Yes/No checkbox
WHO classification of pulmonary hypertension specified (select one: 1, 2, 3, 4, or 5)
Does the patient have a diagnosis of pulmonary arterial hypertension (PAH)?
Yes/No checkbox
Hemodynamic confirmation (at least one of the following documented)
- Diagnosis confirmed by right heart catheterization

Clinical criteria for continuation requests

For continuation of Ventavis, the form requests documentation of ongoing management and benefit:

ALL of the following

Is the medication prescribed by or in consultation with a pulmonologist or cardiologist?
Yes/No checkbox
Is the patient experiencing benefit from therapy as evidenced by disease stability or improvement?
Yes/No checkbox — required for continuation
Date of last treatment (to document ongoing therapy)
Form requests date for continuation requests

Administrative and legal acknowledgement

Form requires provider attestation prior to submission:

ALL of the following

Signature and date of person completing the request
Acknowledgement of legal statement regarding fraudulent information and that the plan may request additional information

Measured Hemodynamic Thresholds

Mean pulmonary arterial pressure (mPAP)<= 20 mmHg or > 20 mmHg

Pulmonary capillary wedge pressure (PCWP)<= 15 mmHg or > 15 mmHg

Pulmonary vascular resistance (PVR)< 3 Wood units or >= 3 Wood units

What Providers Must Do

Prior Authorization

Precertification required

Providers must submit the completed Ventavis precertification form with required clinical and administrative information to Aetna for review prior to initiating therapy or for continuation requests. Submit the completed Ventavis precertification form (including patient, prescriber, product, diagnosis, and dispensing/provider administration sections) to Aetna using the contact methods on the form before start of treatment or when requesting continuation of therapy.

Include completed patient demographics, insurance, prescriber NPI/specialty, requested Ventavis dose/frequency, primary ICD diagnosis, and place/administration information.
For Medicare Advantage Part B use the Medicare request form as indicated on the precertification notice.

Documentation Required

Hemodynamic documentation

For initiation requests document the World Health Organization (WHO) classification of pulmonary hypertension and provide hemodynamic confirmation: either right heart catheterization pretreatment values (mPAP, PCWP, PVR) if performed or indicate that a Doppler echocardiogram was performed. Also indicate on the form if the patient is an infant less than one year of age.

Report pretreatment mPAP (≤20 mmHg or >20 mmHg), PCWP (≤15 mmHg or >15 mmHg), and PVR (<3 Wood units or ≥3 Wood units) when right heart catheterization was performed.
Check the form box confirming whether Doppler echocardiogram was performed.
Check the prescriber specialty box to indicate if prescribed by or in consultation with a pulmonologist or cardiologist.

Documentation Required

Continuation evidence of benefit

For continuation requests, provide documentation that the patient is experiencing benefit from therapy as evidenced by disease stability or improvement, and include the date of last treatment on the precertification form to document ongoing therapy.

Check the continuation box and record the date of last treatment.
Indicate on the form that the patient is experiencing benefit (disease stability or improvement) and confirm prescriber specialty as requested.

Denial Risk

Incomplete forms risk denial

Incomplete or illegible precertification requests may result in Aetna requesting additional information or denial; missing required clinical fields, an absent signature/date, or an ambiguous prescriber specialty can trigger follow-up requests or denial of the request.

All fields must be completed and legible for precertification review.
Request must include the signature and date of the person completing the request.
The plan may request additional information or clarification; materially incomplete forms risk denial.

Clinical and Administrative Background

Ventavis (iloprost inhalation solution) is an inhaled prostacyclin analog used in the management of pulmonary arterial hypertension (PAH). Authorization assessment focuses on clinical confirmation of PAH and involvement of an appropriate specialist; the precertification form requests the WHO classification of pulmonary hypertension, whether PAH is present, and whether the medication is prescribed by or in consultation with a pulmonologist or cardiologist.

When available, hemodynamic confirmation by right heart catheterization is requested and the form captures pretreatment hemodynamic values including mean pulmonary arterial pressure (mPAP) (options: <= 20 mmHg or > 20 mmHg), pulmonary capillary wedge pressure (PCWP) (options: <= 15 mmHg or > 15 mmHg), and pulmonary vascular resistance (PVR) (options: < 3 Wood units or >= 3 Wood units). If right heart catheterization is not documented, the form also asks whether a Doppler echocardiogram has been performed.

Administrative and safety items required for review include completion of the product dose and frequency, prescriber and dispensing/provider details including place of administration and any CPT administration codes, primary diagnosis (ICD code), and the signature/attestation on the form. The form supports both initiation and continuation requests and notes that the plan may request additional information if needed.

Scope & Related Information

This precertification request form and clinical criteria checklist are intended for prescribing providers (particularly pulmonologists and cardiologists) and dispensing or administering providers to submit required clinical and administrative information to Aetna to obtain authorization for initiation or continuation of Ventavis (iloprost inhalation solution).

Providers must complete patient demographics, insurance and prescriber details, specify the Ventavis dose and frequency, indicate the primary ICD diagnosis, and supply the clinical items requested for either initiation (WHO group, PAH diagnosis, hemodynamics or echocardiogram) or continuation (evidence of clinical benefit and date of last treatment) prior to review.

Policy Summary

PayerAetna

PolicyVentavis (iloprost inhalation solution) precertification for pulmonary hypertension

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

If right heart catheterization performed provide pretreatment hemodynamics

Pretreatment mean pulmonary arterial pressure (mPAP)<= 20 mmHg or > 20 mmHg
Form lists options: <=20 mmHg or >20 mmHg
Pretreatment pulmonary capillary wedge pressure (PCWP)<= 15 mmHg or > 15 mmHg
Form lists options: <=15 mmHg or >15 mmHg
Pretreatment pulmonary vascular resistance (PVR)< 3 Wood units or >= 3 Wood units
Form lists options: <3 Wood units or >=3 Wood units

OpenPayer

Ventavis (iloprost inhalation solution) precertification for pulmonary hypertension

Authorization Criteria for Ventavis (iloprost) - Initiation & Continuation

What Providers Must Do

Requested Codes on Precertification Form

Clinical and Administrative Background

Defined Terms

Scope & Related Information