CurrentColorado Rocky Mountain Health PlansPolicy N/A

Cytogam (cytomegalovirus immune globulin) prior authorization for transplant recipients

Defines prior authorization requirements for Cytogam use in transplant recipients (kidney, lung, liver, pancreas, heart) for treatment of active CMV disease when donor positive / recipient negative; applies to Colorado Rocky Mountain Health Plans prior authorization process.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCytogam prior authorization for transplant recipients

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Cytogam prior authorization form with required medical records and recent labs (fax to 1-866-940-7328 or call Pharmacy PA 1-800-310-6826).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16 weeksmaximum approval period

5 yearsdocumentation retention

5covered organs

Coverage Criteria

Approval Criteria

Covered when ALL of the following are met

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCytogam prior authorization for transplant recipients

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Cytogam prior authorization form with required medical records and recent labs (fax to 1-866-940-7328 or call Pharmacy PA 1-800-310-6826).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Indication and serostatus: Diagnosis of active cytomegalovirus (CMV) disease associated with transplantation of the kidney, lung, liver, pancreas, or heart; and the transplant organ must come from a CMV seropositive donor to a CMV seronegative recipient (D+ / R-).

Authorization period: Maximum approval period of 16 weeks for Cytogam therapy.16 weeks

Documentation: Completed prior authorization form plus all copies of medical records (diagnostic evaluations, recent chart notes) and the most recent related labs must be provided; provider must retain documentation for five years.

Incomplete or missing documentation may result in return of the form or denial.

This policy addresses use of Cytogam (cytomegalovirus immune globulin) specifically for the treatment of active cytomegalovirus (CMV) disease associated with transplantation of the kidney, lung, liver, pancreas, or heart. Coverage is limited to cases where the transplant donor was CMV seropositive (D+) and the recipient was CMV seronegative (R-). Any use outside of this clinical context — for transplants of other organs, for prophylaxis rather than treatment, or for donor/recipient serostatus pairings other than D+ to R- — is not described as approved by this policy.

Use of Cytogam for indications other than active CMV disease in the specified transplant setting (D+ donor to R- recipient for kidney, lung, liver, pancreas, or heart transplants) is not supported by this form and therefore is not covered under the approval criteria described here.

Coding

No codes provided on formmixed

No codes listed

Maximum Length of Therapy

Maximum length of therapy16 weeks

Form noteForm must be completed in full; an incomplete form may be returned.

Required documentation retentionProvider must retain copies of all documentation for five years.

Provider Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Cytogam. Submit a completed Cytogam prior authorization form; incomplete forms may be returned and can delay or result in denial.

Fax completed form to 1-866-940-7328
Pharmacy PA Call Center: 1-800-310-6826
Maximum approval period: 16 weeks

Note

Provider Action — Complete Form

Complete and sign the Cytogam PA form and include transplant details (organ type, donor/recipient CMV serostatus, transplant date, weight, dosing, and therapy date range).

Indicate transplant organ (kidney, lung, liver, pancreas, heart)
State donor CMV serostatus (must be seropositive) and recipient serostatus (must be seronegative)
Provide transplant date, patient weight, dosing regimen, and therapy begin/end dates

Documentation Required

Required Documentation

Required documentation: the completed PA form plus copies of medical records, diagnostic evaluations, recent chart notes, and the most recent related labs. Providers must retain documentation for five years.

Include copies of diagnostic evaluations and recent chart notes
Attach most recent related laboratory results
Keep copies of all documentation for five years

Denial Risk

Incomplete Documentation — Denial Risk

Incomplete or missing documentation (including an incomplete PA form) may be returned or lead to denial of the request.

An incomplete form may be returned
Missing medical records or labs increases risk of denial

Definitions

Active CMV disease

DefinitionActive cytomegalovirus (CMV) disease associated with transplantation.

Applies to organ typesKidney, lung, liver, pancreas, or heart.

Role in coverageRequired diagnosis for Cytogam prior authorization under this policy.

CMV serostatus indication (D+ / R-)

DefinitionDonor CMV seropositive to recipient CMV seronegative transplant pair (D+ / R-).

Confirmation on formForm asks: Did the transplant organ come from a cytomegalous seropositive donor? and Was the recipient ... seronegative?

Coverage requirementTransplant must meet D+ donor / R- recipient serostatus for approval.

Candidate Criteria

Candidate criteria

Candidate eligibility for Cytogam prior authorization

Organ types: Recipient received a kidney, lung, liver, pancreas, or heart transplant.

Donor/Recipient serostatus: Donor CMV seropositive and recipient CMV seronegative at time of transplant (D+ / R-).

Clinical diagnosis: Active cytomegalovirus (CMV) disease associated with the transplant.

Contraindications

The document does not list any explicit absolute or relative contraindications to Cytogam. Providers should follow standard clinical judgment and product labeling for contraindications or precautions not specified in this policy.

Evaluation Requirements

Step Therapy

Evaluation requirements — submit clinical records and labs

As part of the PA review, submit all medical records including diagnostic evaluations, recent chart notes, and the most recent related laboratory results along with the completed PA form.

Center Requirements

Note

No transplant center accreditation or volume requirements stated

The policy does not specify any transplant center accreditation, caseload, or volume requirements for submission or approval.

Post-Transplant Coverage

Cytogam therapy

Approval period for Cytogam therapyApproval limited to a maximum of 16 weeks per prior authorization.

Request submissionFax Cytogam PA form to 1-866-940-7328 or contact Pharmacy PA Call Center 1-800-310-6826.

Required recordsAll copies of medical records and most recent related labs must be provided for review.

Background

Cytogam (cytomegalovirus immune globulin) is indicated here for the treatment of active CMV disease associated with transplantation of the kidney, lung, liver, pancreas, or heart when the donor is CMV seropositive and the recipient is CMV seronegative. The policy limits use to that specific clinical scenario and requires documentation and prior authorization per policy procedures.