CurrentAvMedPolicy N/A

Fetroja (cefiderocol) IV prior authorization - Coverage Criteria

This document is a medical prior authorization/step-edit form specifying clinical criteria and documentation required for AvMed coverage of Fetroja (cefiderocol) intravenous therapy, primarily for members with complicated urinary tract infection (cUTI) or pyelonephritis.

Policy Summary

PayerAvMed

PolicyFetroja (cefiderocol) IV prior authorization - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit prior authorization with prescriber signature, current lab cultures (within 7 days), culture sensitivities, and documentation of trials/failures or resistance to required antibiotics.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysculture collection window

All listed oral agentsoral antibiotic requirement

All listed IV agentsIV antibiotic requirement

14 daysauthorization length (new)

72 hrsinpatient threshold

Policy Summary

PayerAvMed

PolicyFetroja (cefiderocol) IV prior authorization - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Initial outpatient therapy for cUTI/pyelonephritis

Covered when ALL of the following are met

Member and diagnostic criteria

Age: Member is 18 years of age or older
Diagnosis of complicated urinary tract infection (cUTI) or pyelonephritis

Cultures and sensitivity: Provider has submitted lab cultures from current hospital admission or office visit collected within the last 7 days; lab cultures must show that the bacteria is sensitive to Fetroja OR show resistance to listed agents as specified.

Oral antibiotic requirement (one of two paths)

Oral trial/failure path: Provider has submitted chart notes documenting trial and failure of ALL: nitrofurantoin; cefdinir; cephalexin; amoxicillin; amoxicillin-clavulanate; ciprofloxacin; levofloxacin; trimethoprim-sulfamethoxazole; and fosfomycin.
Oral resistance path: Cultures (retrieved from most recent office visit or current inpatient admission collected within the last 7 days) show resistance to ALL: nitrofurantoin; cefdinir; cephalexin; amoxicillin; amoxicillin-clavulanate; ciprofloxacin; levofloxacin; trimethoprim-sulfamethoxazole; and fosfomycin.

IV antibiotic requirement (one of two paths)

IV trial/failure path: Provider has submitted chart notes documenting trial and failure of ALL: ciprofloxacin; levofloxacin; ceftriaxone; cefazolin; cefepime; piperacillin-tazobactam; trimethoprim-sulfamethoxazole; gentamicin; tobramycin; amikacin; ertapenem; imipenem-cilastatin; meropenem; imipenem-cilastatin-relebactam; meropenem-vaborbactam; ceftazidime-avibactam; and ceftolozane-tazobactam.
IV resistance path: Cultures (retrieved from most recent office visit or current inpatient admission collected within the last 7 days) show resistance to ALL: ciprofloxacin; levofloxacin; ceftriaxone; cefazolin; cefepime; piperacillin-tazobactam; trimethoprim-sulfamethoxazole; gentamicin; tobramycin; amikacin; ertapenem; imipenem-cilastatin; meropenem; imipenem-cilastatin-relebactam; meropenem-vaborbactam; ceftazidime-avibactam; and ceftolozane-tazobactam.

Authorization timing: For new outpatient starts, length of authorization is Date of Service (14 days).

Continuation of therapy following inpatient administration

Covered when ALL of the following are met

Continuation criteria: Member is currently on Fetroja for more than 72 hours as an inpatient (progress notes must be submitted); provider has submitted inpatient lab culture sensitivity results showing resistance to ALL preferred antibiotics except Fetroja (which is sensitive).

The policy explicitly states that use of medication samples to initiate therapy does not meet step edit / preauthorization criteria. Providers must therefore document prior trials, failures, or culture-proven resistance using verifiable records (e.g., pharmacy claims or chart notes) rather than relying on sample use to satisfy step requirements.

There are no explicit “not medically necessary” statements

Coding, Authorizations, and Timing

Covered HCPCS CodesHCPCSCovered

J0699

Unclassified drugs (used here for Fetroja IV)

inv-06: Culture collection window — collected within the last 7 days

Culture collection windowLab cultures must be collected within the last 7 days (from current hospital admission or office visit).

Source specimensCultures retrieved from the most recent office visit or current inpatient admission are acceptable.

Required documentationProvider must submit lab cultures with culture sensitivity results as part of the authorization request.

inv-07: Authorization length (new start) — Date of Service (14 days)

Authorization length (new start)Length of authorization for new outpatient start: Date of Service (14 days).

Applicable scenarioApplies to New Start requests for initial outpatient administration of Fetroja.

Supporting criteriaMember must be ≥18 years and have diagnosis of cUTI or pyelonephritis as part of new start criteria.

inv-08: Inpatient therapy duration threshold — > 72 hours

Inpatient therapy duration threshold> 72 hours — member must have received Fetroja inpatient for more than 72 hours to qualify for continuation authorization.

Required documentationProgress notes from the inpatient stay must be submitted to verify >72 hours of inpatient therapy.

Culture requirement for continuationProvider must submit inpatient lab culture sensitivity results showing resistance to all preferred antibiotics except Fetroja (sensitive).

What Providers Must Do

Prior Authorization
Prior Authorization Required
Prior authorization required — Prior authorization is required for Fetroja (cefiderocol) IV (J0699). All clinical criteria and documentation must be provided for approval.
Drug: Fetroja (cefiderocol) IV — HCPCS J0699
Fax completed form to 1-877-535-1391

Step Therapy
Step Therapy / Prior Antibiotic Trials
Step therapy / required prior antibiotic trials — Provider must document trial and failure of, or culture-proven resistance to, a comprehensive list of oral and IV antibiotics as specified in the clinical criteria. All required chart notes and culture/sensitivity data must be submitted.
Oral antibiotics (trial and failure OR culture resistance to all): nitrofurantoin; cefdinir; cephalexin; amoxicillin; amoxicillin-clavulanate; ciprofloxacin; levofloxacin; trimethoprim-sulfamethoxazole; fosfomycin
IV antibiotics (trial and failure OR culture resistance to all): ciprofloxacin; levofloxacin; ceftriaxone; cefazolin; cefepime; piperacillin-tazobactam; trimethoprim-sulfamethoxazole; gentamicin; tobramycin; amikacin; ertapenem; imipenem-cilastatin; meropenem; imipenem-cilastatin-relebactam; meropenem-vaborbactam; ceftazidime-avibactam; ceftolozane-tazobactam

Documentation Required
Provider Submission Requirements
Provider submission requirements — Provider must submit a signed prescriber signature (preprinted stamps not valid), member and prescriber information, current lab cultures and culture sensitivity results collected within the last 7 days, and supporting chart notes (including documentation of trials and failures when applicable). For continuation requests, submit progress notes showing inpatient administration >72 hours if applicable.
Prescribing physician signature required (hand-signed; preprinted stamps not valid)
Member and prescriber contact information and phone/fax numbers
Lab cultures and sensitivity results from current admission or office visit collected within the last 7 days
Chart notes documenting trials and failures of listed oral and/or IV antibiotics, or documentation of culture-proven resistance to those agents
For continuation: progress notes demonstrating >72 hours inpatient Fetroja use and inpatient culture sensitivity results

Denial Risk
Incomplete or Illegible Form Risk
Incomplete or illegible form risk — Authorization can be delayed or the request may be denied if the form information is incomplete, incorrect, or illegible. Ensure all required fields and documentation are complete before faxing.
Incomplete, incorrect, or illegible information may delay authorization or result in denial
Ensure phone and fax numbers on the form are correct to avoid unnecessary follow-up

Denial Risk
Denial Conditions
Denial conditions — Requests may be denied if required documentation (lab results, culture sensitivities, chart notes showing trials/failures) is not provided or if criteria are not met.
Missing lab cultures or culture sensitivity results (within 7 days)
Failure to provide chart notes documenting antibiotic trials and failures or culture-proven resistance
Clinical criteria not fully met for diagnosis (e.g., cUTI/pyelonephritis) or member eligibility

Background

Fetroja (cefiderocol) is described in the brief as an intravenous siderophore cephalosporin indicated for certain complicated gram-negative infections, with this prior authorization form focused on use for complicated urinary tract infection (cUTI) or pyelonephritis. The policy requires culture-directed use and documentation of prior antibiotic trials, reflecting its role as a reserved agent when multiple standard oral and IV therapies have failed or show resistance.

Providers should be prepared to submit culture and sensitivity results, chart notes documenting prior antibiotic trials or failures, and other clinical documentation because authorization decisions depend on demonstration of susceptibility to Fetroja or documented resistance to the listed alternative agents.

Definitions and Authorization Types

inv-15: New Start — Authorization for initial outpatient administration with length of authorization documented as Date of Service (14 days).

New Start authorizationAuthorization for initial outpatient administration with length of authorization documented as Date of Service (14 days).

Age and diagnosisMember must be 18 years or older with a diagnosis of complicated urinary tract infection (cUTI) or pyelonephritis.

Required culturesProvider must submit lab cultures from current admission or visit collected within the last 7 days showing susceptibility or specified resistance patterns.

inv-16: Continuation of therapy — Authorization for continuation after inpatient administration when member has received Fetroja inpatient for more than 72 hours with supporting documentation.

Continuation authorizationAuthorization for continuation after inpatient administration when member has received Fetroja inpatient for more than 72 hours with supporting progress notes and inpatient culture sensitivity results.

Inpatient culture requirementSubmitted inpatient culture sensitivity results must show resistance to all preferred antibiotics except Fetroja (which must be shown as sensitive).

Documentation to submitProgress notes verifying inpatient treatment duration (>72 hours) and inpatient lab results must be provided for continuation requests.

OpenPayer

Fetroja (cefiderocol) IV prior authorization - Coverage Criteria

Coverage Criteria for Fetroja (cefiderocol) IV

Coding, Authorizations, and Timing

What Providers Must Do

Background

Definitions and Authorization Types