CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Prolia (denosumab) Prior Authorization Request — Medical Benefit

Form and requirements for requesting outpatient medical benefit authorization for Prolia (denosumab) injections for Highmark Blue Shield of NENY members; intended for prescribing clinicians and facility staff completing the authorization form.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Prolia (denosumab) Prior Authorization Request — Medical Benefit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed Outpatient Medical Injectable Prolia Authorization Request Form and supporting clinical records to 1-833-619-5745.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number to submit form

T-score + DEXA daterequired clinical data elements requested

bisphosphonate trial statusrequired prior therapy information

FRAX scorerisk assessment optional data

Coverage Criteria for Prolia (denosumab)

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Prolia (denosumab) Prior Authorization Request — Medical Benefit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed Outpatient Medical Injectable Prolia Authorization Request Form and supporting clinical records to 1-833-619-5745.

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.

Requested clinical criteria

Information requested to support medical necessity (form collects these elements; authorization contingent on clinical documentation):

Required clinical data: Provide most recent DEXA T-scores and date of the DEXA scan.

T-score and date requested on form.

Prior bisphosphonate therapy: Has the member tried and failed at least one bisphosphonate? If yes, list agent(s), reason for failure, and duration of therapy.

Document name, duration, and reason for failure as requested on form.

Contraindications to bisphosphonates: State any contraindications to bisphosphonate therapy and describe the contraindication.

Requested on form.

Fracture history: Report history of osteoporotic fracture including which bone/site and date of fracture.

Requested on form.

FRAX risk (if used): If a FRAX calculator was used, provide the 10-year risk of major osteoporotic fracture and 10-year risk of hip fracture.

Requested on form if FRAX was used.

Female-specific information: For females, indicate menopausal status (post-menopausal?) and whether the member is taking an adjuvant aromatase inhibitor for breast cancer (identify agent).

Requested on form.

Male-specific information: For males, indicate if receiving androgen deprivation therapy for non-metastatic prostate cancer and identify the medication.

Requested on form; verify member eligibility and benefits through the health plan.

Attachments: Attach pertinent clinical information (e.g., DEXA report, fracture documentation, prior therapy records).

Form includes checkbox for attached records and fax submission instructions.

None explicitly listed on the form.

The form does not specify explicit not medically necessary conditions; however, failure to provide requested clinical data—such as most recent DEXA T-scores and date, documentation of a trial and failure of at least one bisphosphonate (agent, duration, reason), fracture history, or FRAX results—may render the request incomplete and can lead to denial or request for additional information.

Required Provider Actions and Submission

Prior Authorization

Submission method

Prior authorization requests must be submitted using the Outpatient Medical Injectable Prolia Authorization Request Form. Fax the completed form and all required attachments to 1-833-619-5745. This submission method applies to medical benefit requests only.

Fax number: 1-833-619-5745
Form name: Outpatient Medical Injectable Prolia Authorization Request Form
Applies to: Medical benefit only

Documentation Required

Required form and attachments

A completed Outpatient Medical Injectable Prolia Authorization Request Form is required and must include member demographics, requesting physician and facility information, date of service, J-code(s)/diagnosis code(s), and indication of supply method (Buy & Bill or specialty pharmacy). Attach all pertinent clinical documentation (DEXA report with T-scores and date, fracture history, FRAX score, prior therapy records).

Member name, date of birth, UMI
Requesting physician name, NPI, address, office contact phone and fax
Facility name, facility NPI, facility address
Date of service, J-code(s), diagnosis code(s)
Indicate Buy & Bill or Supplied by Specialty Pharmacy (include pharmacy name and NPI if applicable)
Attach: DEXA report (T-scores + date), fracture documentation, FRAX score, prior medication records

Prior Authorization

Prior bisphosphonate trial

Authorization will be considered only after documentation of a trial and failure of at least one bisphosphonate is provided. Include the bisphosphonate name(s), duration of therapy, and reason for failure (e.g., lack of efficacy, intolerance, contraindication). If a bisphosphonate is contraindicated, document the specific contraindication.

List bisphosphonate(s) tried and reason for failure
Document duration of each bisphosphonate trial
If contraindicated, provide specific contraindication details

Denial Risk

Incomplete clinical information

Failure to provide requested clinical information (recent DEXA T-scores with date, prior bisphosphonate trial details including duration and reason for failure or documented contraindication, fracture history, and FRAX score when used) may delay review or result in denial of the request.

Required clinical items: DEXA T-scores + date, bisphosphonate trial details, fracture history (site and date), FRAX scores if used
Incomplete submissions may be delayed or denied

Key Definitions

T-score

DefinitionDEXA bone mineral density T-score used to assess osteoporosis severity (provide most recent T-scores and date of DEXA).

Source of measurementMeasured by dual-energy X-ray absorptiometry (DEXA) and recorded as a T-score on the authorization form.

Use in authorizationMost recent DEXA T-scores and the date of the DEXA scan are requested to support medical necessity for Prolia (denosumab).

Contextual dataT-scores are submitted alongside fracture history and prior bisphosphonate trial information to justify treatment need.

FRAX

DefinitionFRAX: the 10-year calculated risk of major osteoporotic fracture and 10-year risk of hip fracture (reported if a FRAX calculator was used).

Use in authorizationIf a FRAX calculator was used, provide the member's 10-year major osteoporotic fracture risk and 10-year hip fracture risk on the form.

Role with other dataFRAX risk estimates are provided in conjunction with DEXA T-scores, fracture history, and prior therapy details to support coverage decisions.

J-code(s): (blank on form)	J-code field provided for billing code entry
Diagnosis Code(s): (blank on form)	Diagnosis code field provided for ICD-10 entry

OpenPayer

Outpatient Prolia (denosumab) Prior Authorization Request — Medical Benefit

Coverage Criteria for Prolia (denosumab)

Billing and Code Fields

Required Provider Actions and Submission

Background

Key Definitions