CurrentAvMedPolicy N/A

Tigecycline (Tygacil) medical prior authorization

Prior authorization and step-edit criteria for inpatient/outpatient medical use of tigecycline (Tygacil) for AvMed members, including required documentation and clinical trial/failure or culture-based criteria for ABSSSI, cIAI, CABP, and continuation after inpatient use.

Policy Summary

PayerAvMed

PolicyTigecycline (Tygacil) medical prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation including prescriber signature, dosing, length of therapy, diagnosis/ICD, culture results (within 7 days) and chart notes showing trials/failures or resistance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysstandard length of authorization per request

J3243HCPCS code listed for Tygacil (medical)

7 daysrequired timeframe for submitting culture results

trial & failure of ALLstep/failure requirement

Coverage Criteria

inv-01: ABSSSI (New Start)

Covered when ALL of the following are met for ABSSSI (New Start):

ABSSSI approval criteria: Member has 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 bacteria is sensitive to tigecycline; and member meets ONE of the antimicrobial history options (see children).

Antimicrobial history options - Oral: Either (A) provider submits chart notes documenting trial and failure of ALL the following oral antibiotics: penicillin VK, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, and linezolid; OR (B) cultures (from current admission or office visit within the last 7 days) show resistance to ALL those oral antibiotics.

Antimicrobial history options - IV: Either (A) provider submits chart notes documenting trial and failure of ALL the following IV antibiotics: penicillin G, nafcillin, ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, vancomycin, daptomycin, clindamycin, and linezolid; OR (B) cultures (from current admission or office visit within the last 7 days) show resistance to ALL those IV antibiotics.

Policy Summary

PayerAvMed

PolicyTigecycline (Tygacil) medical prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-02: cIAI (New Start)

Covered when ALL of the following are met for complicated intra-abdominal infection (cIAI) with limited/no alternatives (New Start):

cIAI approval criteria: Member has diagnosis of complicated intra-abdominal infection (cIAI) with limited or no alternative treatment options; provider has submitted lab cultures from current hospital admission or office visit collected within the last 7 days; lab cultures show that bacteria is sensitive to tigecycline; and member meets ONE of the antimicrobial history options (see children).

Antimicrobial history options - IV: Either (A) provider submits chart notes documenting trial and failure of ALL the following IV antibiotics: ciprofloxacin, levofloxacin, ceftriaxone, cefazolin, cefepime, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, ertapenem, imipenem-cilastatin, and meropenem; OR (B) cultures (from current admission or office visit within the last 7 days) show resistance to ALL those IV antibiotics.

inv-03: CABP (New Start)

Covered when ALL of the following are met for community-acquired bacterial pneumonia (CABP) without pseudomonas risk (New Start):

CABP approval criteria: Member has diagnosis of community-acquired bacterial pneumonia (CABP) with no pseudomonas risk; provider has submitted lab cultures from current hospital admission or office visit collected within the last 7 days; lab cultures show that bacteria is sensitive to tigecycline; and member meets ONE of the antimicrobial history options (see children).

Antimicrobial history options - Oral: Either (A) provider submits chart notes documenting trial and failure of ALL the following oral antibiotics: amoxicillin, amoxicillin-clavulanate, dicloxacillin, doxycycline, azithromycin, cefdinir, cefpodoxime, levofloxacin, ciprofloxacin, and linezolid; OR (B) cultures (from current admission or office visit within the last 7 days) show resistance to ALL those oral antibiotics.

Antimicrobial history options - IV: Either (A) provider submits chart notes documenting trial and failure of ALL the following IV antibiotics: ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, azithromycin, levofloxacin, ciprofloxacin, vancomycin, and linezolid; OR (B) cultures (from current admission or office visit within the last 7 days) show resistance to ALL those IV antibiotics.

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Tygacil (tigecycline) medical use (HCPCS J3243). Requests must use the AvMed medical prior authorization form (prescribing physician signature required; preprinted stamps not valid). Fax completed form and supporting documentation to 1-877-535-1391. For Medicare members, applicable NCDs/LCDs and Medicare Benefit Policy Manual rules apply.

HCPCS: J3243
Fax: 1-877-535-1391
Prescriber signature required (no preprinted stamps)

Step Therapy

Step Therapy / Culture-Resistance Requirement

Trial and failure of ALL listed preferred antibiotics is required for most indications, OR lab cultures collected within the last 7 days must demonstrate resistance to those listed agents. Requirements vary by diagnosis (e.g., ABSSSI, cIAI, CABP).

Step requirement: trial and failure of all listed oral or IV preferred antibiotics per indication
Alternative: cultures within 7 days showing resistance to all listed agents

Documentation Required

Required Documentation

Authorization may be delayed or denied if required documentation is missing or incomplete. Provide complete member and prescriber information, drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight (if applicable) with date, labs, culture results, and relevant progress/clinic notes. For continuation requests, submit inpatient progress notes when member has been on therapy >72 hours.

Member name, AvMed #, DOB
Prescriber name, signature, NPI, office contact, phone, fax
Drug form/strength, dosing schedule, length of therapy
Diagnosis and ICD code, weight and date obtained
Lab results and culture sensitivity reports (collected within 7 days)
Chart/progress notes documenting trials/failures of listed agents or inpatient progress notes for >72-hour inpatient use

Denial Risk

Incomplete Documentation Risks Denial

If the prior authorization form is incomplete, incorrect, illegible, or missing required supporting documentation (e.g., lab results, cultures, progress notes), the request can be delayed or denied. Ensure all required fields are completed and supporting evidence is attached to avoid denial.

Incomplete/illegible forms risk delay or denial
Missing lab/culture results or progress notes may result in denial

Background

Tigecycline (Tygacil) is requested primarily for serious bacterial infections including acute bacterial skin and skin structure infection (ABSSSI), complicated intra-abdominal infections (cIAI) when limited or no alternatives exist, and community-acquired bacterial pneumonia (CABP) without pseudomonas risk. Requests for these indications routinely require culture and sensitivity data and documentation of prior trials and failures of multiple preferred antibiotics or demonstration of resistance to those alternatives.

For coverage consideration, providers must submit relevant documentation such as recent culture results (typically collected within the last 7 days), chart notes showing trials and failures of listed oral or IV antibiotics when required, and inpatient progress notes for continuation requests. Prior authorization is required for medical use (HCPCS J3243), and initiation based on samples alone is not acceptable.

OpenPayer

Tigecycline (Tygacil) medical prior authorization

Coverage Criteria

Coding and Billing

Provider Actions and Documentation

Background

Definitions