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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsHighmark Blueshield Neny Aloxi Prior Auth Coverage…
    Ask Trek AI about this page
    CurrentHighmark Blueshield NenyPolicy N/A

    Outpatient Chemotherapy Aloxi (palonosetron) Request Form — Coverage Criteria

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    A form and checklist used by providers to request outpatient Aloxi (palonosetron) under the medical benefit for chemotherapy-associated or post-operative nausea/vomiting; intended for ordering/attending providers and servicing facilities submitting authorization information to Highmark. Affects providers submitting prior authorization requests for Aloxi.

    Policy Summary
    PayerHighmark Blueshield Neny
    PolicyOutpatient Chemotherapy Aloxi (palonosetron) Request Form — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit completed Aloxi request form including HCPCS and ICD-10 codes, clinical answers about prior Kytril/Zofran trials or contraindications, and attach supporting documentation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1HCPCS code field present
    2comparative agents asked about

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    24
    PONV timeframe (hrs)

    Coverage Criteria

    Authorization criteria (form-based)

    Coverage is considered when clinicians provide documented clinical rationale and prior antiemetic trial history.

    Form completion requirements: Completed form including member demographics, payer, ordering provider and servicing facility details, HCPCS code, ICD-10 diagnosis, and requested start date must be submitted.

    Supported by administrative fields on the form.

    Clinical justification pathways: Either: (A) Member is receiving chemotherapy and Aloxi is requested for prevention of chemotherapy-associated nausea/vomiting with documentation of the chemotherapy regimen; OR (B) Aloxi is requested for prevention of post-operative nausea and vomiting for up to 24 hours following surgery.

    Form asks specifically about regimen and PONV use up to 24 hours.

    Prior agent trial or contraindication: Provider must document that the member has tried and failed BOTH Kytril (granisetron) and Zofran (ondansetron), or document contraindications to these agents.

    Failure/contraindication question present on form.

    The Aloxi request form does not list any explicit exclusions. The document is a form-based prior authorization request that collects clinical and administrative information to determine coverage, but it does not specify services or diagnoses that are expressly excluded from consideration.

    The form does not define conditions that are automatically considered not medically necessary. Coverage determinations are made based on the clinical information submitted (chemotherapy regimen, prior antiemetic trials, contraindications, intended use for PONV up to 24 hours, and benefit/eligibility verification).

    Coding

    Requested HCPCS CodeHCPCS
    HCPCS CodeField for submitting the procedure/billing code for Aloxi infusion (specific code to be entered by provider)
    ICD-10 Diagnosis CodesICD-10
    ICD-10Field for submitting diagnosis code(s)

    Provider Actions & Submission Requirements

    Prior Authorization

    Prior authorization submission requirement

    Submit the completed Outpatient Chemotherapy Aloxi Request Form (medical benefit) with the HCPCS code and ICD-10 diagnosis code(s) entered, and answer the clinical questions about prior antiemetic trials and contraindications. Attach supporting documentation for any reported prior failures or contraindications when submitting the request.

    • Enter HCPCS Code and ICD-10 diagnosis code(s) on the form.
    • Answer clinical questions about chemotherapy regimen and prior antiemetic trials.
    • Attach documentation of prior failures or documented contraindications.
    Step Therapy

    Prior trial or contraindication must be recorded

    Document whether the member has tried and failed BOTH Kytril (granisetron) and Zofran (ondansetron), or document a contraindication to one or both agents on the form.

    • If trials failed, indicate both Kytril and Zofran were tried and failed.

    Initial Therapy Criteria

    Initial therapy information

    Initial authorization considerations as collected on the form:

    Clinical questions to answer: Provide the member's chemotherapy regimen; indicate whether the member has tried and failed BOTH Kytril (granisetron) and Zofran (ondansetron); list any contraindications to these agents; and state if Aloxi is requested for prevention of post-operative nausea and vomiting for up to 24 hours.

    Answers are captured on the request form and guide initial approval.

    Step Therapy Requirements

    RequirementForm field / expected response
    Prior trial of Kytril (granisetron) and Zofran (ondansetron)Yes/No — provider must indicate whether the member has tried and failed BOTH agents on the form
    Documented contraindication to Kytril or ZofranIf contraindication, list agent(s) and rationale in the provided field on the form

    Site of Care

    Note

    Form applies to outpatient chemotherapy; include servicing facility details

    Use this form for outpatient chemotherapy under the medical benefit and provide servicing facility/vendor information (Name, NPI, Address) on the form.

    • Form is for outpatient chemotherapy (medical benefit only).
    • Provide servicing facility/vendor Name, NPI, and Address on the form.

    Definitions

    PONV timeframe — Post-operative nausea and vomiting (PONV) prevention up to 24 hours following surgery.
    DefinitionPost-operative nausea and vomiting (PONV) prevention is defined on the form as up to 24 hours following surgery.
    Where askedThe request form explicitly asks whether Aloxi is to be used for prevention of PONV for up to 24 hours following surgery.
    Documentation requiredIf PONV is the indication, providers must indicate this on the form and attach pertinent clinical information documenting the surgical context and timing.
    Interaction with prior trialsThe form also requires documentation of prior trials or contraindications to Kytril (granisetron) and Zofran (ondansetron), even when Aloxi is requested for PONV up to 24 hours.
    Implication for authorizationRequests stating Aloxi for PONV up to 24 hours will be reviewed as part of the same authorization form and are subject to the same documentation and eligibility verification requirements.

    Background

    Palonosetron (Aloxi) is identified on the form as an antiemetic for prevention of chemotherapy-induced nausea and vomiting and may be requested for prevention of post-operative nausea and vomiting (PONV) for up to 24 hours after surgery. The form collects the member's chemotherapy regimen and prior antiemetic history to support a medical benefit authorization.

    Policy Summary
    PayerHighmark Blueshield Neny
    PolicyOutpatient Chemotherapy Aloxi (palonosetron) Request Form — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit completed Aloxi request form including HCPCS and ICD-10 codes, clinical answers about prior Kytril/Zofran trials or contraindications, and attach supporting documentation.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & Submission RequirementsInitial Therapy CriteriaStep Therapy RequirementsSite of CareDefinitionsBackground
  1. If contraindicated, list the specific contraindication(s) on the form.
    2. Documentation Required

    Attach required clinical documentation

    Attach all pertinent clinical information and fully answer the form’s clinical questions, including the member's chemotherapy regimen, prior trials of Kytril and Zofran, any contraindications, and whether Aloxi is being requested for PONV up to 24 hours.

    • Provide the member's chemotherapy regimen.
    • Indicate prior antiemetic trial history and list contraindications if present.
    • State whether Aloxi is requested for prevention of post-operative nausea and vomiting (up to 24 hours).
    • Mark whether clinical records are attached (YES/NO).
    Billing Rule

    Provide complete patient and billing details

    Provide administrative and billing details on the form: member date of birth, member ID (UMI), payer type (Medicare or Commercial), servicing facility/vendor name, NPI, address, requested start date of service, HCPCS code, and ICD-10 diagnosis code(s).

    • Member Date of Birth and Member ID (UMI).
    • Select payer type: Medicare or Commercial.
    • Servicing facility/vendor: name, NPI, and address.
    • Requested start date of service.
    • Enter HCPCS Code and ICD-10 diagnosis code(s).
    Denial Risk

    Risk: missing documentation or unverified eligibility

    Failure to attach pertinent clinical information or to verify member eligibility and benefits may prevent processing of the request or result in denial.

    • Verify member eligibility and benefits through the health plan before submission.
    • Ensure all requested clinical attachments are included; indicate attachments on the form.