CurrentCignaPolicy IP0125

Vericiguat (Verquvo) — Medical Necessity and Coverage Criteria

This policy governs medical necessity and coverage criteria for vericiguat (Verquvo) for adults with symptomatic chronic heart failure with reduced ejection fraction under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyVericiguat (Verquvo) — Medical Necessity and Coverage Criteria

Policy CodePolicy IP0125

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateJan 1, 2025

Key ActionObtain prior authorization; approvals granted up to 12 months when medical necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum patient age for coverage

<45%required LVEF prior to initiation

6 monthsHF hospitalization lookback

3 monthsoutpatient IV diuretics lookback

12 moauthorization duration

Medical Necessity and Coverage Criteria

Medical Necessity Criteria (Initial)

Covered when ALL of the following are met

Heart failure criteria for vericiguat

Age 18 years or older>= 18 years
Document patient age.
Recent decompensation
- Hospitalization for heart failure within the last 6 monthshospitalization for HF within last 6 months
- Outpatient IV diuretics:

Policy Summary

PayerCigna

PolicyVericiguat (Verquvo) — Medical Necessity and Coverage Criteria

Policy CodePolicy IP0125

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateJan 1, 2025

Key ActionObtain prior authorization; approvals granted up to 12 months when medical necessity criteria are met.

SourceLink

On This Page

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Key Eligibility Metrics

inv-04: Left ventricular ejection fraction — < 45%

Eligibility LVEF thresholdLeft ventricular ejection fraction less than 45% prior to initiation of Verquvo

Clinical contextPolicy applies to symptomatic chronic heart failure with reduced ejection fraction as defined by LVEF criteria

Documentation requirementRecord of LVEF measurement prior to starting therapy must be provided

inv-05: Age — >= 18 years

Minimum age18 years of age or older

Age documentationPatient age must be documented in clinical records to support eligibility

Applies toAdults only (no pediatric coverage specified)

inv-06: Hospitalization lookback — hospitalization for HF within last 6 months

Required lookback for hospitalizationHospitalization for heart failure was required within the last 6 months

Supporting evidenceDischarge summary or hospital admission record documenting HF hospitalization should be provided

Alternative to hospitalizationIf hospitalization not present, outpatient IV diuretics within 3 months may qualify instead

inv-07: Outpatient IV diuretics lookback — outpatient IV diuretics within last 3 months

Required lookback for outpatient IV diureticsOutpatient intravenous diuretics were given within the last 3 months

DocumentationRecords of outpatient IV diuretic administration or infusion center notes should be provided

Alternative to hospitalizationQualifies as an alternative to a HF hospitalization within 6 months

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required. Initial and reauthorization approvals are granted for up to 12 months when medical necessity criteria are met.

Applies when vericiguat (Verquvo) is prescribed for heart failure meeting the policy's medical necessity criteria
Initial and reauthorization approvals: up to 12 months

Step Therapy

No step therapy requirements are specified in this policy.

Documentation Required

Required Clinical Documentation

Documentation must demonstrate that the patient meets the medical necessity criteria for vericiguat (Verquvo): age ≥18 years; left ventricular ejection fraction <45% prior to initiation; AND either a hospitalization for heart failure within the last 6 months or outpatient intravenous diuretics within the last 3 months. Also document that the medication is prescribed by, or in consultation with, a cardiologist. Include supporting clinical records (hospital discharge summary, infusion records, echocardiogram or other documentation of LVEF) and treatment plan.

Denial Risk

Non‑covered Uses

Use of vericiguat (Verquvo) for any indication other than the specified heart failure criteria is considered experimental, investigational or unproven and is not covered.

Drug Background and Rationale

Verquvo (vericiguat) is a soluble guanylate cyclase stimulator indicated to reduce the risk of cardiovascular death and heart failure hospitalization in adults with symptomatic chronic heart failure with reduced ejection fraction. This policy applies to adults age ≥18 years with left ventricular ejection fraction <45% who have experienced either a hospitalization for heart failure within the prior 6 months or required outpatient intravenous diuretics within the prior 3 months. Prior authorization is required; approvals (initial and reauthorization) are granted for up to 12 months when medical necessity criteria are met, and therapy should be prescribed by or in consultation with a cardiologist.

Definitions and Clinical Terms

inv-13: Heart failure with reduced ejection fraction (HFrEF) — Heart failure subtype with left ventricular ejection fraction generally ≤40%; here policy uses LVEF <45% as the eligibility threshold for...

DefinitionHeart failure with reduced ejection fraction (HFrEF): HF subtype characterized by reduced LVEF (policy uses LVEF <45% as the eligibility threshold)

Typical LVEF rangeHFrEF generally defined in literature as LVEF ≤40%; policy uses slightly higher cutoff for vericiguat eligibility

Clinical implicationPatients with symptomatic chronic HF and LVEF below the specified threshold following HF hospitalization or need for outpatient IV diuretics are candidate population