CurrentAvMedPolicy N/A

Qutenza (capsaicin 8% topical patch) prior authorization

Defines prior authorization requirements and clinical criteria for coverage of Qutenza (capsaicin 8% topical system) for neuropathic pain (postherpetic neuralgia and diabetic peripheral neuropathy) for AvMed members.

Policy Summary

PayerAvMed

PolicyQutenza (capsaicin 8% topical patch) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with prescriber signature and supporting clinical documentation including baseline and current NPRS scores and prior therapy history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4maximum quantity per 90 days (1120 billable units)

3 moinitial approval duration

3 more-approval duration

PHN, DPNdocumented covered indications

Coverage Criteria for Qutenza (capsaicin 8% topical system)

Initial Authorization — PHN

Covered when ALL of the following are met for PHN

PHN initial criteria: Requested medication will be used in the management of neuropathic pain associated with postherpetic neuralgia (PHN); provider has documented the member's baseline Numerical Pain Rating Scale (NPRS) score; member has postherpetic neuralgia that has persisted for at least 6 months following healing of herpes zoster rash (i.e., crusting of the skin vesicles); painful areas to be treated are NOT located on the face, above the hairline of the scalp, and/or in proximity to mucous membranes; member has tried and had an inadequate response (or contraindication) to BOTH a tricyclic antidepressant (e.g., amitriptyline, nortriptyline, maprotiline, desipramine) AND a gabapentinoid (e.g., pregabalin, gabapentin)

All lines must be checked and documentation provided

Initial Authorization — DPN

Covered when ALL of the following are met for DPN

DPN initial criteria: Requested medication will be used for neuropathic pain due to diabetic peripheral neuropathy (DPN); provider has documented the member's baseline Numerical Pain Rating Scale (NPRS) score; member has painful, distal, symmetrical, sensorimotor polyneuropathy due to diabetes that has persisted for at least 1 year prior to screening; all other causes of pain in the feet have been ruled out; member has tried and had an inadequate response (or contraindication) to BOTH an antidepressant (e.g., duloxetine, venlafaxine, amitriptyline, nortriptyline, maprotiline, desipramine) AND a gabapentinoid (e.g., pregabalin, gabapentin)

Policy Summary

PayerAvMed

PolicyQutenza (capsaicin 8% topical patch) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with prescriber signature and supporting clinical documentation including baseline and current NPRS scores and prior therapy history.

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.

All lines must be checked and documentation provided

Reauthorization

Covered when ALL of the following are met for reauthorization

Reauthorization criteria: Member continues to meet all initial authorization criteria; member has experienced an absence of unacceptable toxicity from the drug (e.g., severe application site pain and burning, hypertension, decrease in sensory function); provider has documented the member's current Numerical Pain Rating Scale (NPRS) score; member has experienced an improvement in pain based on the NPRS compared to baseline

Documentation required to support continued benefit and tolerability; all documentation, including lab results, diagnostics, and/or chart notes, must be provided

Coverage excludes treatment of painful areas that are on the face, located above the hairline of the scalp, or in proximity to mucous membranes. Requests must document the anatomical location(s) of the painful area(s) to confirm they do not fall within these excluded regions.

Coding and Quantity Limits

Covered HCPCSHCPCSCovered

J7336

Qutenza (capsaicin 8% topical system)

Quantity limit

Quantity limit4 patches (1120 billable units) every 90 days

Max billable units1120 billable units per 90 days

Max patches per period4 patches per 90 days

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Qutenza (capsaicin 8% topical system) (J7336). Initial authorization is for 3 months; reauthorization is for 3 months. Quantity limit: 4 patches (1120 billable units) every 90 days. Note: Qutenza 8% Patch must be applied by a health care provider in a well-ventilated area.

Prior authorization required: J7336
Initial authorization: 3 months
Reauthorization: 3 months
Quantity limit: 4 patches (1120 billable units) every 90 days
Application must be performed by a health care provider in a well-ventilated area

Step Therapy

Required Prior Therapies

Member must have tried and had an inadequate response to, or have contraindications to, specified first-line therapies before Qutenza will be approved. Documentation of trials/failures or contraindications must be provided.

For Postherpetic Neuralgia (PHN): trial and inadequate response or contraindication to BOTH a tricyclic antidepressant (e.g., amitriptyline, nortriptyline, maprotiline, desipramine) AND a gabapentinoid (e.g., pregabalin, gabapentin)
For Diabetic Peripheral Neuropathy (DPN): trial and inadequate response or contraindication to BOTH an antidepressant (e.g., duloxetine, venlafaxine, amitriptyline, nortriptyline, maprotiline, desipramine) AND a gabapentinoid (e.g., pregabalin, gabapentin)

Documentation Required

Required Signatures and Clinical Documentation

Prescriber signature (hand-signed; preprinted stamps not valid) and printed name are required. All clinical documentation supporting each checked criterion must be provided, including baseline Numerical Pain Rating Scale (NPRS) score, chart notes, labs, diagnostics, and documentation of trial/failure or contraindication to required therapies. Incomplete, incorrect, or illegible requests may be delayed or denied.

Prescriber must sign and clearly print name on request (preprinted stamps not valid)
Provide baseline NPRS score for the member
Attach chart notes, diagnostic results, and lab data as applicable
Document duration of condition (e.g., PHN ≥ 6 months after healing; DPN ≥ 1 year prior to screening)

Note

Drug and Dosing Details

Submit complete drug and dosing details: drug name/form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight (if applicable) and date weight obtained, and location(s) of painful areas to be treated. Painful areas located on the face, above the hairline, or near mucous membranes are exclusions.

Drug Name/Form/Strength: Qutenza (capsaicin 8% topical system)
Provide dosing schedule and length of therapy
Provide diagnosis and ICD code
Specify weight and date if applicable
Document location(s) of painful areas — must NOT be on the face, above the hairline of the scalp, or near mucous membranes

Denial Risk

Missing Clinical Criteria or Documentation

Missing required clinical criteria or supporting documentation may result in denial. Ensure every checked clinical criterion is supported by corresponding documentation; absent documentation for trials, baseline scores, duration of disease, or exclusions (e.g., painful area location) increases denial risk.

All checked clinical criteria must have supporting documentation or request may be denied
Failure to document prior therapy trials/failures or contraindications will risk denial
Incomplete or illegible information (including missing prescriber signature) may delay or deny authorization

Required Conservative Treatment Documentation

Must document failures or contraindications to listed therapies

Provider must document trial failures or contraindications to the therapies listed below before initial authorization

Conservative treatment requirements for PHN: For PHN: member has tried and had an inadequate response (or contraindication) to BOTH a tricyclic antidepressant (e.g., amitriptyline, nortriptyline, maprotiline, desipramine) AND a gabapentinoid (e.g., pregabalin, gabapentin)

Must document failures or contraindications to both classes; verification may include chart notes or pharmacy claims

Conservative treatment requirements for DPN: For DPN: member has tried and had an inadequate response (or contraindication) to BOTH an antidepressant (e.g., duloxetine, venlafaxine, amitriptyline, nortriptyline, maprotiline, desipramine) AND a gabapentinoid (e.g., pregabalin, gabapentin)

Must document failures or contraindications to both classes; verification may include chart notes or pharmacy claims

Frequency and Application Limits

Qutenza patch application

ProcedureQutenza (capsaicin 8% topical system) patch application — up to 4 patches (1120 billable units)

Application settingPatch should be applied by a health care provider in a well-ventilated area (clinic or specialty setting)

Documentation to includeProvide dosing schedule, length of therapy, diagnosis, and supporting clinical documentation to avoid delay

Imaging Requirements

Note

Imaging not explicitly required for Qutenza

Imaging is not explicitly required for Qutenza prior authorization; provide diagnostics as applicable to support the diagnosis (for example, to rule out other causes of foot pain in DPN).

Imaging not explicitly required for Qutenza
Provide diagnostics when applicable to support the diagnosis or to rule out other causes

Background

Qutenza is a high‑concentration capsaicin topical system (8% capsaicin) applied by a health care provider for localized neuropathic pain. Administration should be performed in a clinical setting with documentation of the member's baseline Numerical Pain Rating Scale (NPRS) score and the treated anatomical location.

Definitions

Postherpetic Neuralgia (PHN)

DefinitionPain associated with herpes zoster that has persisted for at least 6 months following healing (crusting) of the herpes zoster rash.

Minimum durationAt least 6 months after healing of zoster rash

Location exclusionPainful areas located on the face, above the hairline of the scalp, or in proximity to mucous membranes are excluded from treatment

Diabetic Peripheral Neuropathy (DPN)

DefinitionPainful, distal, symmetrical, sensorimotor polyneuropathy due to diabetes that has persisted for at least 1 year and after ruling out other causes of foot pain.

Minimum durationPersisted for at least 1 year prior to screening

Diagnostic requirementAll other causes of pain in the feet must be ruled out

Not Covered

Application of Qutenza to the face, areas above the hairline of the scalp, or sites near mucous membranes is not covered. Prior authorization requests must specify the exact location(s) of the painful area(s) to verify they are not within these excluded regions.