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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAHCA Dalvance Prior Auth Coverage | OpenPayer
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    CurrentAgency for Health Care AdministrationPolicy N/A

    Dalvance (dalbavancin) Prior Authorization Criteria

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    This policy governs Medicaid fee-for-service prior authorization for Dalvance (dalbavancin) used to treat qualifying bacterial skin and skin structure infections. Coverage requires documentation of vancomycin failure or vancomycin resistance in the infecting gram-positive organism.

    Policy Summary
    PayerAgency for Health Care Administration
    PolicyDalvance (dalbavancin) Prior Authorization Criteria
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit documentation of vancomycin trial and failure or a culture and sensitivity report showing vancomycin resistance.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2 weeksMaximum authorization length
    500 mgAvailable vial strength
    Vancomycin failure or resistanceRequired qualifying evidence
    Skin infectionCovered infection category

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    Coverage Criteria

    Initial Therapy Criteria

    Covered when all of the following are met:

    Initial therapy

    • Qualifying infection: The patient has been diagnosed with a bacterial skin or skin structure infection likely due to a gram-positive organism, such as cellulitis or wound abscess.

    • Vancomycin evidence

      • Vancomycin failure: Medical documentation shows a trial and failure of vancomycin for the current active infection.
      • Vancomycin resistance: A culture and sensitivity report indicates that the gram-positive organism is resistant to vancomycin.

    Dalvance is not indicated for infection sites other than bacterial skin and skin structure infections, including urinary tract infections and pneumonia.

    Prior Authorization and Documentation

    Prior Authorization

    Initial Prior Authorization Criteria

    Prior authorization is required for Dalvance® when the patient has a qualifying bacterial skin or skin structure infection likely due to a gram-positive organism, such as cellulitis or a wound abscess.

    • Document the diagnosis and clinical site of infection.
    • The infection must be likely caused by a gram-positive organism.
    Step Therapy

    Vancomycin Prerequisite

    The patient must have documented trial and failure of vancomycin for the current active infection, unless culture and sensitivity results show that the gram-positive organism is resistant to vancomycin.

    • Submit evidence of vancomycin trial and failure for the current active infection.
    • A culture and sensitivity report demonstrating vancomycin resistance satisfies the prerequisite.
    Documentation Required

    Required Clinical Documentation

    Submit medical records supporting the qualifying infection and the applicable vancomycin requirement. Documentation must include either evidence of a vancomycin trial and failure or a culture and sensitivity report indicating vancomycin resistance.

    • Medical records identifying the bacterial skin or skin structure infection.
    • Documentation of vancomycin trial and failure for the current active infection, or culture and sensitivity results showing resistance to vancomycin.
    Denial Risk

    Nonqualifying Infection Site

    Dalvance® is not indicated for infection sites that do not qualify as a bacterial skin or skin structure infection likely due to a gram-positive organism. Requests for other sites, such as urinary tract infections or pneumonia, may be denied.

    • Nonqualifying sites include urinary tract infections and pneumonia.
    • Confirm that the infection is a qualifying skin or skin structure infection before submitting the request.
    Denial Risk

    Vancomycin Evidence Missing

    A request may be denied when the required vancomycin trial and failure for the current active infection is not documented and no culture and sensitivity report demonstrates resistance of the gram-positive organism to vancomycin.

    • Include vancomycin failure evidence or qualifying culture and sensitivity documentation.
    • Missing or insufficient prerequisite documentation creates a denial risk.

    Therapeutic Context

    Dalvance (dalbavancin) is addressed for bacterial skin and skin structure infections likely caused by gram-positive organisms, such as cellulitis or a wound abscess.

    Initial Therapy Criteria

    Initial Therapy Criteria

    Covered when all of the following are met:

    Initial therapy

    • Qualifying infection: The patient has been diagnosed with a bacterial skin or skin structure infection likely due to a gram-positive organism.

      Examples include cellulitis or wound abscess.

    • Vancomycin evidence

      • Vancomycin failure: Medical documentation shows a trial and failure of vancomycin for the current active infection.
      • Vancomycin resistance: A culture and sensitivity report indicates that the gram-positive organism is resistant to vancomycin.

    Step Therapy Requirement

    StepRequirementCoverage
    1Try and fail vancomycin for the current active infection, unless culture and sensitivity testing documents that the infecting gram-positive organism is resistant to vancomycin.Required
    Policy Summary
    PayerAgency for Health Care Administration
    PolicyDalvance (dalbavancin) Prior Authorization Criteria
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit documentation of vancomycin trial and failure or a culture and sensitivity report showing vancomycin resistance.
    SourceLink
    On This Page
    Coverage CriteriaPrior Authorization and DocumentationTherapeutic ContextInitial Therapy CriteriaStep Therapy Requirement