CurrentAvMedPolicy N/A

Cefiderocol (Teflaro) IV prior authorization for ABSSSI and CABP with MRSA risk

Defines clinical and documentation requirements for prior authorization and step-edit approval of intravenous cefiderocol (Teflaro, J0712) for acute bacterial skin and skin structure infections (ABSSSI) and community-acquired bacterial pneumonia (CABP) with MRSA risk for AvMed members.

Policy Summary

PayerAvMed

PolicyCefiderocol (Teflaro) IV prior authorization for ABSSSI and CABP with MRSA risk

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain and submit current lab cultures with sensitivity results and documentation of trials/failures or resistance to listed antibiotics when requesting prior authorization for Teflaro (J0712).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysstandard length of authorization

72 hrsminimum inpatient duration

7 daysculture recency

J0712billing code

Coverage Criteria for Cefiderocol (Teflaro) IV

Initial authorization — ABSSSI

Covered when ALL of the following are met

ABSSSI initial criteria: Member has a diagnosis of acute bacterial skin and skin structure infection (ABSSSI); provider has submitted lab cultures from current hospital admission or office visit collected within the last 7 days; lab cultures show that the bacteria is sensitive to Teflaro (cefiderocol).

Antibiotic trial or resistance (oral)

Required oral agents: penicillin VK, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, linezolid

Antibiotic trial or resistance (IV)

Required IV agents:

Policy Summary

PayerAvMed

PolicyCefiderocol (Teflaro) IV prior authorization for ABSSSI and CABP with MRSA risk

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Initial authorization — CABP with MRSA risk

Covered when ALL of the following are met

CABP initial criteria: Member has a diagnosis of community-acquired bacterial pneumonia (CABP) with MRSA risk; provider has submitted lab cultures from current hospital admission or office visit collected within the last 7 days; lab cultures show that the bacteria is sensitive to Teflaro (cefiderocol).

Antibiotic trial or resistance (oral)

Required oral agents: amoxicillin, amoxicillin-clavulanate, dicloxacillin, doxycycline, azithromycin, cefdinir, cefpodoxime, levofloxacin, ciprofloxacin, linezolid

Antibiotic trial or resistance (IV)

Required IV agents: ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, azithromycin, levofloxacin, ciprofloxacin, vancomycin, linezolid

Billing and Coding

Covered HCPCS CodeHCPCSCovered

J0712

Teflaro (cefiderocol) IV

inv-07: Inpatient duration to qualify for outpatient continuation

Threshold> 72 hours

Applies toMembers currently receiving Teflaro inpatient who are being considered for outpatient continuation

Documentation requiredProgress notes confirming inpatient Teflaro administration >72 hours

Supporting lab requirementInpatient culture sensitivity results showing resistance to all preferred antibiotics except Teflaro

inv-08: Recency of culture collection

Recency requirementLab cultures must be collected within the last 7 days

Where samples may be fromCurrent hospital admission or office visit (most recent)

PurposeTo demonstrate organism sensitivity or resistance relevant to approval criteria

Provider Actions, Documentation, and Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required for Teflaro (cefiderocol) IV (J0712). Use the medical prior authorization/step-edit request form and fax to 1-877-535-1391. Authorization may be delayed or denied if submitted information is not complete, correct, or legible.

Drug Requested: Teflaro® (cefiderocol) IV (J0712) (Medical)
Fax completed form to 1-877-535-1391

Step Therapy

Step Therapy and Continuation Requirements

Step therapy and continuation requirements apply. Initial and continuation approvals are contingent on meeting the clinical criteria, documentation of prior trials or culture-proven resistance to listed agents, and submission of recent lab culture sensitivity results (within the last 7 days where specified). Length of authorization varies by indication (e.g., Date of Service/14 days for certain indications; continuation following inpatient administration requires documentation of inpatient use >72 hours).

Length of Authorization: Date of Service (14 days) for some indications
Continuation requires member to be currently on Teflaro inpatient >72 hours with progress notes
Recent lab cultures (within 7 days) demonstrating sensitivity/resistance as specified in criteria

Documentation Required

Prescriber Signature and Required Submission Data

Prescriber signature is required on the authorization form (preprinted stamps are not valid). Provide complete member and prescriber information, including member name, AvMed number, date of birth, prescriber name, prescriber signature and date, office contact name, phone and fax numbers, and NPI. Also provide drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code if applicable, weight and date obtained when relevant.

Prescriber signature required (no preprinted stamps)
Member Name, AvMed #, Date of Birth
Prescriber Name, Signature, Date, Office Contact, Phone, Fax, NPI
Drug Form/Strength, Dosing Schedule, Length of Therapy, Diagnosis, ICD code (if applicable), Weight and date weight obtained

Denial Risk

Authorization Delay Risk

Authorization can be delayed if the request information is not complete, correct, or legible. Incomplete clinical documentation (e.g., missing culture results, chart notes documenting prior antibiotic trials, or unclear dosing/diagnosis information) may result in delays or denials. Ensure all requested supporting documentation (labs, diagnostics, chart notes) is included to avoid processing delays.

Incomplete or illegible forms may delay authorization
Include lab results, diagnostics, and chart notes to support each checked clinical criterion

Background

Cefiderocol (Teflaro) is covered for treatment of acute bacterial skin and skin structure infections (ABSSSI) and community‑acquired bacterial pneumonia (CABP) with MRSA risk only when the clinical and documentation criteria are met. The policy requires up-to-date lab cultures collected within the last 7 days that identify the organism and demonstrate sensitivity to Teflaro, and it requires documentation of trials and failures of the specified alternative oral and IV antibiotics (or culture-proven resistance to those agents). Continuation after inpatient initiation additionally requires the member to have received inpatient Teflaro for > 72 hours with progress notes and inpatient culture sensitivities showing resistance to all preferred antibiotics except Teflaro.

Definitions

inv-14: New Start — Initiation of outpatient therapy requiring documentation of diagnosis, culture/sensitivity within 7 days, and either documented trials/failures...

DefinitionInitiation of outpatient therapy requiring documentation of diagnosis, culture/sensitivity within 7 days, and either documented trials/failures of all listed oral or IV antibiotics or culture-proven resistance to those agents.

Required diagnosis examplesABSSSI or CABP with MRSA risk (as applicable to the request)

Culture requirementProvider must submit lab cultures from current admission or office visit collected within the last 7 days showing bacteria sensitive to Teflaro (for approval)

Antibiotic trials or resistanceProvider must either submit chart notes documenting trial and failure of all specified oral and/or IV antibiotics OR submit cultures showing resistance to all listed agents

inv-15: Continuation of therapy following inpatient administration — Member currently receiving Teflaro inpatient for >72 hours with progress notes and inpatient culture sensitivity showing resistance to alternatives.

DefinitionContinuation when member is currently receiving Teflaro inpatient for more than 72 hours with progress notes and inpatient culture sensitivity showing resistance to alternatives.

Inpatient duration> 72 hours of inpatient Teflaro administration (progress notes must be submitted)

Culture requirementInpatient lab culture sensitivity results must show resistance to all preferred antibiotics except Teflaro (which is sensitive)

Applicable diagnosesABSSSI or CABP with MRSA risk