CurrentCentenePolicy CP.PHAR.203

Cosyntropin (Cortrosyn) - Diagnostic Use

Covers medical necessity and prior authorization criteria for Cortrosyn/cosyntropin when used as a diagnostic agent for screening adrenocortical insufficiency for Centene-affiliated health plans (Commercial, HIM, Medicaid). Applies to providers submitting requests for this product.

Policy Summary

PayerCentene

PolicyCosyntropin (Cortrosyn) - Diagnostic Use

Policy CodePolicy CP.PHAR.203

Change TypeNo material changes

Effective DateApr 1, 2016

Next Review Date

Key ActionSubmit documentation (office chart notes, lab results or other clinical information) showing the member meets all approval criteria; prior authorization is for a single diagnostic dose and generic cosyntropin should be used unless contraindicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Single doseapproval duration

0.25 mgdose ≥2 yrs

0.125 mgdose <2 yrs

J0834billing code

Coverage Criteria

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Initial Approval Criteria

Covered when ALL of the following are met:

Presumed Adrenocortical Insufficiency (must meet all): 1) Prescribed for diagnostic testing of adrenocortical insufficiency;

Product selection: 2) If Cortrosyn is requested, member must use generic cosyntropin unless contraindicated or clinically significant adverse effects are experienced;

Other diagnoses/indications

For other indications not specifically listed:

Other diagnoses/indications (must meet 1 or 2): 1) If the drug has undergone a label change within the last 6 months that is not yet reflected in this policy, follow the referenced formulary/no-coverage or non-formulary policy for the relevant line of business (see policy references); OR 2) If the requested use (e.g., diagnosis, age, dosing regimen) is not listed under the policy exclusions and criterion 1 does not apply, refer to the off-label use policy for the relevant line of business (CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, CP.PMN.53 for Medicaid).refer to referenced policies

See related policy references for specific line of business

Non‑FDA approved indications that are not specifically addressed in this policy are not authorized unless the provider supplies sufficient documentation of efficacy and safety in accordance with the applicable off‑label use policy for the member’s line of business (CP.CPA.09 for Commercial, HIM.PA.154 for Health Insurance Marketplace, or CP.PMN.53 for Medicaid) or other applicable evidence of coverage documents.

Re‑authorization is not permitted; approval is limited to the initial diagnostic administration only. Requests for repeat administrations beyond the single approved diagnostic dose will not be authorized under the Presumed Adrenocortical Insufficiency criteria. The policy approves a single dose only, and providers must document that the member meets the initial approval criteria before authorization is granted.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for diagnostic testing with Cortrosyn/cosyntropin. Requests for Cortrosyn should be redirected to generic cosyntropin unless contraindicated or the member has experienced clinically significant adverse effects with the generic.

PA required for diagnostic testing of adrenocortical insufficiency
Redirect Cortrosyn requests to generic cosyntropin unless contraindicated or adverse reaction

Documentation Required

Required Documentation

Provider must submit documentation (such as office chart notes, laboratory results, and other clinical information) that supports the member meets all approval criteria for presumed adrenocortical insufficiency. Documentation should demonstrate indication for testing, age-appropriate dosing, and any contraindications to generic cosyntropin when branded Cortrosyn is requested.

Examples: office notes, lab results (e.g., cortisol levels), prior medication history, rationale for branded Cortrosyn if applicable

Denial Risk

Denial Risk / Triggers

Applications lacking the required clinical documentation or adequate justification for off‑label use (per CP.CPA.09, HIM.PA.154, CP.PMN.53 as applicable) will be denied. Re-authorization is not permitted; members must meet initial approval criteria for coverage.

Denial triggers: missing office notes or lab results
Denial triggers: insufficient documentation to support use for non‑FDA indications
Re-authorization for continued dosing is not permitted

Policy Summary

PayerCentene

PolicyCosyntropin (Cortrosyn) - Diagnostic Use

Policy CodePolicy CP.PHAR.203

Change TypeNo material changes

Effective DateApr 1, 2016

Next Review Date

SourceLink

On This Page

OpenPayer

Cosyntropin (Cortrosyn) - Diagnostic Use

Coverage Criteria

Coding and Dosing

Provider Actions & Requirements

Background

Definitions