CurrentColorado Rocky Mountain Health PlansPolicy N/A

Massachusetts Standard Form for Chemotherapy and Supportive Care Prior Authorization Requests

A standardized prior authorization request form for chemotherapy and supportive care medications used by providers to request authorization from the health plan; it governs submission requirements and clinical/administrative information to support cancer treatment requests for members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMassachusetts Standard Form for Chemotherapy and Supportive Care Prior Authorization Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete the standardized chemotherapy/supportive care prior authorization form or use the health plan portal and attach required supporting documentation (progress notes, chemo orders, labs, pathology, imaging).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections I-Vform sections present (demographics through exceptions)

Attachments requiredrequired attachments

Step therapy exceptionsstep therapy exception field

Biomarker fieldbiomarker field present

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General coverage prerequisites

Covered when ALL of the following are provided with the request

Form completion: Completed prior authorization form or portal submission with treatment start date and request type (new, retrospective, re-authorization)

Clinical data: Diagnosis/tumor histology, ECOG score, current line of treatment and prior therapies tried, and whether tumor mutation/biomarker/genetic testing was performed (with results if available)

Supporting documentation: Attach relevant supporting documents: labs, imaging, chemotherapy orders, pathology, and progress notes to justify medical necessity

The form itself does not list any explicit clinical exclusions. Any coverage exclusions applicable to a requested chemotherapy or supportive care therapy are determined by the health plan's coverage policies and benefit rules referenced elsewhere, not by this standardized prior authorization form. Reviewers should consult the plan's medical necessity and exclusion policies when an exclusion question arises.

Regimen details required	Examples of fields to provide
Drug name (each agent in the regimen)	Exact drug name as listed on the request form
Route of administration	IV, oral, subcutaneous, intramuscular, etc., as specified on the form
Dose	Dose per administration (mg, mcg, units) as entered on the form
Schedule / frequency	Frequency (e.g., q2w, q3w) or specific schedule details from the request
Number of cycles or refills requested	Cycles or refills field for new, retrospective, or re-authorization requests
Request type and treatment start date	Indicate New, Retrospective, or Re-Authorization and provide treatment start date
FDA approval status for the diagnosis (if applicable)	Field asking whether agent is FDA approved for the diagnosis (re-authorization section)
Dose rounding / single-use vial reporting	Indicate whether provider is requesting dose rounding or single-use vials as noted on the form

What Providers Must Do / Submission Requirements

Documentation Required

Required supporting documentation

Providers must attach supporting documentation necessary to determine medical necessity. Required attachments include PROGRESS NOTES, CHEMO ORDERS, LAB RESULTS, PATHOLOGY REPORTS, and IMAGING RESULTS. Failure to include these supporting documents may result in delays or denial of the request. Use the Massachusetts standardized chemotherapy/supportive care prior authorization form or the health plan portal and include any additional data referenced in the plan's medical necessity criteria.

Progress notes documenting diagnosis, treatment plan, and clinical course
Chemotherapy orders or treatment plan (dose, route, frequency, cycles/refills)
Relevant laboratory results (baseline and recent labs supporting therapy)
Pathology reports confirming diagnosis or biomarkers
Imaging reports that support clinical need
Documentation of prior therapies and outcomes (for step therapy exceptions: dates, adverse reactions, inadequate response)
Any additional office notes or supporting records referenced on the form

Tumor Mutation / Biomarker / Genetic Testing

Biomarker / Genetic Testing (tumor mutations) requirements

Tumor/biomarker testing field presentForm asks: 'Has the patient been screened for tumor mutations/biomarkers/genetic testing?' with options Yes / No / Unknown

If tested, report resultsForm requests: 'If so, what tumor mutations/biomarkers/genetic testing result has the patient been tested for?' — provider must supply specific results if testing performed

Use of resultsReported testing/results are used to support therapy selection per plan policy (biomarker information supports medical necessity and regimen choice)

Key Definitions and Indications

Line of Treatment

DefinitionLine of Treatment = the current sequence of anticancer therapy (e.g., first-line, second-line) documented on the form; provider must indicate which line is current

Prior therapiesForm asks: 'What therapies has the patient previously tried?' — list prior systemic, targeted, or other anticancer therapies

Current treatment statusForm asks if the patient is currently being treated with the requested regimen(s)? (Yes / No / Unknown) to contextualize line of therapy

Supportive Care Indication Selection

Bone-strengthening agents indicationsIf bone strengthening or bone antiresorptive agents are requested, select indication: Osteoporosis or Bone Metastases

ESA indications (list)If ESAs requested, form provides checkboxes for: CKD; Chemotherapy-Induced Anemia (CIA); Adjuvant Breast Cancer; MDS; Anemia of Chronic Disease (ACD)

Indication selection requiredProvider must select the specific indication for supportive agents on the form to justify medical necessity and coverage

Form Purpose and Scope

This standardized prior authorization form collects the clinical details required to evaluate chemotherapy and supportive care requests, including diagnosis, tumor histology, line of treatment and therapies previously tried, whether the patient is currently receiving the requested regimen, and whether the patient has been screened for tumor mutations/biomarkers/genetic testing. It also captures provider and site-of-care information, and lists required attachments such as labs, imaging, chemo orders, pathology, and progress notes to support medical necessity determinations.