CurrentColorado Rocky Mountain Health PlansPolicy N/A

Pulmonary Arterial Hypertension (PAH) Prior Authorization Request Form - Washington (Community Plan)

A Washington prior authorization request form for PAH medications used by Colorado Rocky Mountain Health Plans (UnitedHealthcare form) collecting member, provider, medical, prior medication trial, and clinical information to support PAH agent coverage decisions. The form requests documentation of diagnosis, WHO group and functional class, prior therapies/trials, contraindications, combination-therapy plans, specialist involvement, and chart notes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPulmonary Arterial Hypertension (PAH) Prior Authorization Request Form - Washington (Community Plan)

Policy CodePolicy N/A

Change TypeForm / prior authorization requirements

Effective Date

Next Review Date

Key ActionComplete and fax the entire form (including chart notes) to 866-940-7328 and allow at least 24 hours for review; call 800-310-6826 with questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Prior authorization form type

WHO Group 1-4Covered Indication Categories

Chart notesDocumentation requirement

Coverage Summary

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This is a Washington prior authorization request form for Pulmonary Arterial Hypertension (PAH) agents used by Colorado Rocky Mountain Health Plans (UnitedHealthcare form). The form collects member, provider, and medical details and specifically requests documentation of diagnosis and ICD-10 code, WHO group and functional class, prior medication trials (names, strengths, directions, dates, and reasons for failure/discontinuation), contraindications and acute vasoreactivity test (AVT) information, intended combination-therapy plans, specialist involvement (Cardiology or Pulmonology), and required chart notes and prescriber signature. Coverage stance is mixed, meaning adjudication depends on meeting the documented clinical criteria and prior therapy requirements; reviewers will require the specified documentation (including chart notes) to authorize therapy and may deny or request more information if criteria or documentation are incomplete.

PAH Prior Authorization Form - Key Requirements

Prior authorization form type1

Covered Indication CategoriesWHO Group 1-4

Documentation requirementChart notes required

Acute vasoreactivity test contraindication thresholdSBP < 90 mmHg; cardiac index < 2 L/min/m2; or PH functional class IV

Authorization Criteria (Form Fields and Required Clinical Information)

PAH Agent Authorization Information

Form requires documentation and affirmative responses to clinical criteria and prior therapy trials to support authorization:

PAH Agent Authorization Information - Top Level

New vs Continuation: Indicate whether request is new therapy or continuation of therapy; if continuation, provide start date and documentation of disease stability for continuation requests.
Supported by form Section A fields and Clinical and Drug Specific Information question on continuation and disease stability.
Diagnosis and ICD-10: Provide specific diagnosis and ICD-10 code.
Section C requests diagnosis and ICD-10 code.
Diagnosis / Indication (select at least one)
- PAH WHO Group 1: Pulmonary arterial hypertension (PAH) World Health Organization (WHO) Group 1
- WHO Functional Class II: WHO Functional class II symptoms
- WHO Functional Class III: WHO Functional class III symptoms
- WHO Functional Class IV: WHO Functional class IV symptoms
- Persistent/Recurrent CTEPH: Persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH) (WHO group 3 or 4)
- Other (specify)
Prior Medication Trials: Document prior medication trials: list medication name, strength, directions, dates of therapy, and reason for failure/discontinuation.
Section D collects prior medication trial details.
Calcium channel blocker (CCB) trial or rationale
- Tried CCB: Patient tried a calcium channel blocker
- CCB Contraindication: Contraindication to a calcium channel blocker
- Negative AVT: Patient had a negative response to acute vasoreactivity test (AVT)
- AVT Not Indicated: Acute vasoreactivity test not indicated for the patient
- AVT Contraindicated: Acute vasoreactivity test is contraindicated (SBP < 90 mmHg; cardiac index < 2 L/min/m2, or PH functional class IV)
Combination therapy check (if applicable)
- PDE inhibitor + sGC stimulator: Combination of phosphodiesterase inhibitor and soluble guanylate cyclase stimulator
- Selexipag + parenteral prostanoid: Combination of selexipag and parenteral prostanoid
- None of the above
Selexipag-specific requirement: For selexipag requests: document history of failure, contraindication, or intolerance to an endothelin receptor antagonist (Yes/No).
Specific question for selexipag per form.
Specialist involvement: Indicate whether prescribed by or in consultation with a specialist (Cardiology or Pulmonology) or other (specify).
Form asks prescriber specialty/consultation.
Attachments and Signature: Attach chart notes; prescriber signature, prescriber specialty, and date are required.
Chart notes and prescriber signature required (CHART NOTES ARE REQUIRED WITH THIS REQUEST).

What the Provider Must Do

Prior Authorization

Submit PAH Prior Authorization Form

Complete the entire PAH prior authorization form and fax it (including chart notes) to 866-940-7328. Allow at least 24 hours for review. For questions, call 800-310-6826.

Documentation Required

Attach Chart Notes and Trials

Attach chart notes and provide documentation of prior medication trials including medication names, dates of therapy, and reasons for failure/discontinuation. For continuation requests, include documentation of disease stability. Include evidence of specialist consultation (Cardiology or Pulmonology as applicable), and ensure the prescriber signature and prescriber specialty are present on the request.

Chart notes
Prior medication trials: medication name, dates, reason for failure/discontinuation
Documentation of disease stability for continuation requests
Specialist consultation (Cardiology or Pulmonology)
Prescriber signature and prescriber specialty

Documentation Required

Include Acute Vasoreactivity Test Information or Rationale

Document whether an acute vasoreactivity test (AVT) was performed and the test response. If AVT was not performed, provide the clinical rationale or document that AVT was contraindicated. Contraindication criteria include SBP < 90 mmHg; cardiac index < 2 L/min/m2; or PH functional class IV.

Indicate if AVT was performed and report the response
If AVT not done, provide clinical rationale or indicate contraindication
Contraindication threshold: SBP < 90 mmHg; cardiac index < 2 L/min/m2; or PH functional class IV

Background

This PAH agent prior authorization request form is used to collect the required information to adjudicate coverage for PAH medications. It asks the requester to indicate whether the request is for a new therapy or continuation of therapy and, for continuation, to provide start date and documentation of disease stability.

The form collects a specific diagnosis and ICD-10 code and asks the requester to select the appropriate indication (including PAH WHO Group 1, WHO Functional classes II, III, or IV, CTEPH, or other).

Prior medication trials must be documented by medication name, strength, directions, dates of therapy, and reason for failure or discontinuation. The form specifically asks about a calcium channel blocker (CCB) trial or rationale (including contraindication or AVT results) and requires documentation if the patient did not receive AVT or if AVT was contraindicated.

Combination-therapy plans must be indicated (options include combination of a phosphodiesterase inhibitor and a soluble guanylate cyclase stimulator, or combination of selexipag and a parenteral prostanoid), and for selexipag requests the form asks whether there is a history of failure, contraindication, or intolerance to an endothelin receptor antagonist.

The form requires that the request be prescribed by or in consultation with a specialist (Cardiology or Pulmonology) when applicable and mandates that chart notes and the prescriber signature, specialty, and date be attached for adjudication.

PAH: Pulmonary arterial hypertension.

CTEPH: Chronic thromboembolic pulmonary hypertension.

AVT: Acute vasoreactivity test.

OpenPayer

Pulmonary Arterial Hypertension (PAH) Prior Authorization Request Form - Washington (Community Plan)

Coverage Summary

Authorization Criteria (Form Fields and Required Clinical Information)

What the Provider Must Do

Coding

Background