CurrentColorado Rocky Mountain Health PlansPolicy N/A

Panretin (topical tretinoin) prior authorization for AIDS-related Kaposi's Sarcoma

Defines Florida Medicaid prior authorization requirements for Panretin when used topically to treat AIDS-related Kaposi's sarcoma lesions; affects prescribers, pharmacies, and Medicaid recipients in Florida.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPanretin (topical tretinoin) prior authorization for AIDS-related Kaposi's Sarcoma

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required medical records and labs; retain documentation for five years.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearmaximum approval length

<10maximum total KS lesions allowed

2-3 cmallowed lesion size

5 yrsprovider must retain documentation

Coverage Criteria for Panretin (topical tretinoin)

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Initial Coverage Criteria

Covered when ALL of the following are met

Panretin coverage criteria: Indication: topical treatment for AIDS-related Kaposi's sarcoma lesions.see node texts

Lesion count: Total number of lesions must be less than ten.< 10

Lesion size must be between 2 and 3 centimeters.2-3 cm

Concurrent therapy: Patient is not currently on any systemic anti-KS (Kaposi's sarcoma) treatment.

Recipients currently on systemic anti-KS treatment are excluded from coverage while on that therapy.

Documentation and prior authorization: Completed prior authorization form and required medical records (diagnostic evaluations, recent chart notes) and most recent related labs submitted and retained by provider for five years.

Form must be completed in full; maximum approval length = one year.

Initial Therapy

Initial authorization requirements

Initial authorization: Indication: topical treatment of AIDS-related Kaposi's sarcoma; total lesions less than ten; lesion size 2–3 cm; patient not on systemic anti-KS therapy; completed PA form and required records/labs submitted.lesion count and size

Form must be completed in full; incomplete forms may be returned. Maximum approval length = one year.

Continuation Therapy

Continuation approvals

Continuation/renewal: Maximum approval length is one year; renewal requires updated documentation and continued meeting of initial criteria.one year

Provider must retain documentation for five years.

Coding and Clinical Parameters

No codes providedmixed

No codes listed

inv-05: Total number of lesions — < 10

Total number of KS lesionsLess than 10 lesions

Denial thresholdRequests with 10 or more lesions may be denied

Relevance to coverageRequirement for initial and continuation authorization

inv-06: Lesion size — 2-3 cm

Allowed lesion sizeBetween 2 and 3 centimeters

Denial thresholdLesions outside the 2–3 cm range are not supported by this criteria

ApplicabilityRequirement applies to initial authorization and renewals

Provider Actions, Requirements, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required for topical Panretin (alitretinoin) use. Maximum approval length = one year. Incomplete forms may be returned; the prescriber must complete the PA form in full.

Fax PA form to 1-866-940-7328
Pharmacy PA Call Center: 1-800-310-6826

Documentation Required

Required Documentation

Completed prior authorization form and copies of medical records are required for review. Include diagnostic evaluations, recent chart notes, and most recent related labs. The provider must retain copies of all documentation for five years.

Include recipient Medicaid ID, DOB, recipient full name, prescriber name and NPI, prescriber contact and signature on the PA form

Denial Risk

Denial Triggers

Requests will be denied if any of the following are present: total lesions ≥ 10, lesion size outside 2–3 cm, or the recipient is currently on systemic anti‑KS therapy.

Denial triggers: ≥10 lesions; lesion size not between 2–3 cm; recipient currently receiving systemic anti‑KS treatment

Background

Panretin (topical tretinoin) is addressed here for the topical treatment of AIDS-related Kaposi's sarcoma lesions. The policy defines specific patient-level thresholds for coverage: a total lesion count of less than 10, lesion size between 2 and 3 centimeters, and that the patient is not receiving systemic anti-KS therapy. Requests that meet these criteria are considered under prior authorization review; uses that exceed lesion count or size limits or occur while on systemic therapy are not supported by this authorization criteria.