CurrentAvMedPolicy Pub. 100-2

Medical prior authorization and step-edit request for Ycanth (cantharidin) topical solution 0.7%

Form and clinical criteria governing prior authorization and step-edit requests for Ycanth (cantharidin) topical solution 0.7% for AvMed members; applies to providers requesting medical benefit coverage (J7354).

Policy Summary

PayerAvMed

PolicyMedical prior authorization and step-edit request for Ycanth (cantharidin) topical solution 0.7%

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a signed prior authorization request (fax 1-877-535-1391) with chart notes or pharmacy paid claims verifying prior therapy and diagnosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 yrsminimum member age for approval

90 dayslookback period for prior therapy failure

3 monthsreauthorization interval

J7354billing HCPCS code listed

Coverage Criteria for Ycanth (cantharidin) topical solution 0.7%

inv-01: Initial Therapy

Covered when ALL of the following are met

Initial Authorization Criteria: Member is 2 years of age or older; Member has a diagnosis of molluscum contagiosum (ICD-10: B08.1); Member has tried and failed at least ONE of the following in the last 90 days (salicylic acid; topical retinoids e.g., adapalene, tretinoin; imiquimod 5% cream; cryotherapy; pulsed dye laser).

Documentation (chart notes and/or pharmacy paid claims) must verify prior therapies and diagnosis.

inv-02: Reauthorization

Reauthorization covered when ALL of the following are met

Reauthorization Criteria: Member was previously approved for Ycanth through the AvMed medical department in the past 6 months; Member has continued presence of molluscum lesions; Reauthorization requested for up to 3 months (4 treatment doses).

All documentation supporting continued lesions and prior approval must be provided.

Policy Summary

PayerAvMed

PolicyMedical prior authorization and step-edit request for Ycanth (cantharidin) topical solution 0.7%

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a signed prior authorization request (fax 1-877-535-1391) with chart notes or pharmacy paid claims verifying prior therapy and diagnosis.

SourceLink

On This Page

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Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Requests for coverage that rely on sample use in lieu of documented prior therapy will not satisfy the requirement to demonstrate failure of prior treatments and may be denied or delayed.

Initial Authorization Requirements

inv-13: Initial Authorization

Initial authorization criteria for Ycanth

Initial: Member >=2 years; diagnosis of molluscum contagiosum (ICD-10: B08.1); failure of at least one listed prior therapy within 90 days (salicylic acid; topical retinoids; imiquimod 5% cream; cryotherapy; pulsed dye laser).

Chart notes or pharmacy paid claims must verify prior treatments.

Reauthorization / Continuation

inv-14: Reauthorization/Continuation

Reauthorization rules

Continuation: Member has previous AvMed approval within past 6 months; continued presence of molluscum lesions documented; reauthorization interval up to 3 months (4 treatment doses).

Documentation required.

Coding and Diagnosis

Covered HCPCSHCPCSCovered

J7354

Ycanth (cantharidin) topical solution 0.7% (Medical)

Relevant ICD-10 diagnosisICD-10

B08.1

Molluscum contagiosum

inv-06: Minimum age — >= 2 years

Minimum age for approvalMember is 2 years of age or older

Threshold detail>= 2 years

Documentation requirementChart notes or other documentation must support age and other clinical criteria

Actions Required of Providers

Prior Authorization

Prior Authorization Required

A signed prior authorization request must be submitted to AvMed (fax 1-877-535-1391). The prescribing physician must sign and clearly print their name (preprinted stamps not valid). All other information may be completed by office staff. Incomplete, incorrect, or illegible information can delay authorization.

Fax prior authorization requests to 1-877-535-1391
Practitioner phone contact not required if form is complete and legible

Step Therapy

Step-edit: prior therapy failure required

Member must have tried and failed at least one specified prior therapy within the last 90 days. To support each therapy checked, provide chart notes and/or pharmacy paid claims verifying prior therapy.

Required prior therapies include salicylic acid, topical retinoids (e.g., adapalene, tretinoin), imiquimod 5% cream, cryotherapy, or pulsed dye laser
Verification via chart notes and/or pharmacy paid claims within 90 days is required

Documentation Required

Required supporting documentation

Provide documentation to support each clinical criterion checked. Documentation must include chart notes, diagnostics, and/or pharmacy paid claims as applicable. For prior therapies, submit pharmacy paid claims or chart notes to verify failure. For Medicare members, ensure compliance with applicable NCDs/LCDs.

Include chart notes documenting diagnosis (e.g., molluscum contagious ICD-10: B08.1) and member age
Provide pharmacy paid claims for prior therapies when listed
Attach any relevant diagnostics or lab results

Denial Risk

Incomplete or insufficient documentation

Authorization can be delayed or the request may be denied if the form information is incomplete, incorrect, or illegible. Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

If urgent review is needed (lack of treatment could seriously jeopardize life/health or function), call AvMed Pre-Authorization Department
Samples do not satisfy prior therapy requirement

Step Therapy Requirements

Requirement	Details
Prior trial required	Member must have tried and failed at least ONE of the following within the last 90 days (verified by chart notes and/or pharmacy paid claims): salicylic acid; topical retinoids (e.g., adapalene, tretinoin); imiquimod 5% cream; cryotherapy; pulsed dye laser.

Site of Care / Dispensing

Billing Rule

Site-of-care selection required (office or Proprium Rx)

Indicate whether medication will be provided in the physician's office or via the specialty pharmacy (Proprium Rx) on the form; either site is acceptable as specified.

Check the box for Physician's office OR Specialty Pharmacy - Proprium Rx on the PA form.

Background

Ycanth (cantharidin) topical solution 0.7% is used for treatment of molluscum contagiosum and the prior authorization form requires documentation of diagnosis (ICD-10: B08.1) and prior treatment attempts. Reauthorization is available for up to 3 months (4 treatment doses) when the member was previously approved through AvMed within the past 6 months and there is continued presence of molluscum lesions. All supporting documentation (chart notes, pharmacy paid claims, diagnostics) must be provided to substantiate prior therapies and ongoing disease.

Definitions

inv-12: Molluscum contagiosum — ICD-10: B08.1

Indicated diagnosis (ICD-10)B08.1 — Molluscum contagiosum

Usage contextDiagnosis must be documented on the form to support Ycanth (cantharidin) topical solution 0.7% treatment

Supporting documentationChart notes or other clinical documentation must verify the diagnosis when submitting prior authorization