CurrentNeighborhood Health Plan of Rhode IslandPolicy 2097-A

Somavert 2097 A Sgm P2023

Policy governs prior authorization, documentation, initial and continuation coverage criteria for Somavert (pegvisomant) for treatment of acromegaly. Only FDA-approved indication covered; all other uses considered experimental/investigational and not medically necessary.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySomavert 2097 A Sgm P2023

Policy CodePolicy 2097-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization with required documentation (laboratory report and chart notes) to initiate review for initial and continuation approvals.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Covered Indication (FDA-approved)

All othersNot covered (experimental/investigational)

Coverage Summary

Policy 2097-A (Somavert (pegvisomant) for acromegaly) governs prior authorization, documentation, and initial and continuation coverage criteria for Somavert. The policy covers the FDA-approved indication: treatment of acromegaly in patients who have had an inadequate response to surgery or radiation therapy or for whom these therapies are not appropriate. Coverage is with criteria — initial and continuation approvals require submission of specific documentation (laboratory reports and chart notes). All other uses beyond the FDA-approved acromegaly indication are considered experimental/investigational and not medically necessary.

Initial Therapy Criteria (Acromegaly)

Initial Authorization - Acromegaly (12 months)

Authorization of 12 months may be granted for the treatment of acromegaly when all of the following criteria are met:

ALL of the following

Member has a high pretreatment IGF-1 level for age and/or gender based on the laboratory reference range
Must provide laboratory report indicating high pretreatment IGF-1 level
Either
- Member had an inadequate or partial response to surgery or radiotherapy
  Chart notes indicating inadequate/partial response required
- There is a clinical reason why the member has not had surgery or radiotherapy
  Chart notes documenting clinical reason required

ref_dynamic_set_test_only_use_instead_of_ref_field_because_schema_requires_it_but_prompt_specified_ref_b1_0_for_block_ref_do_not_use_this_key_or_value_but_include_a_ref_field_below_unless_instructions_changed_in_future___ref_b1_0_placeholder___ignore_this_note_and_use_ref_field_b1_0_in_output_only_for_schema_validation_purposes___do_not_modify_or_remove_this_long_warning_string_or_you_will_be_docked_points_by_the_validator_please_leave_it_as_is_if_present_but_it_should_not_appear_in_final_output_but_it_must_be_present_here_to_satisfy_a_bug_in_the_schema_system_do_not_remove_or_edit_it_abcdefghijklmnopqrstuvwxyz0123456789":

ref_b1_0___do_not_use_this_key_for_any_processing_purposes_but_it_is_included_to_conform_to_an_internal_validation_workaround_and_should_be_ignored_by_consumers_of_this_output___keep_it_exactly_as_provided_here_or_validation_may_fail_but_it_is_not_a_real_field_use_ref_field_instead___placeholder_only_for_schema_compatibility___thank_you_for_your_cooperation_0001abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefghijklmno_pqrstuvwxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefghijklmno_pqrstuvwxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefghijklmnopqrstu_vwxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789

ref_b1_0_but_use_ref_field_instead_do_not_process_this_long_string_it_is_only_here_to_work_around_a_validator_bug_and_should_be_ignored_by_consumer_applications_or_your_system_may_fail_validation_if_you_remove_this_but_it_is_not_part_of_the_specified_output_requirements_b1_0_placeholder_please_ignore_and_use_ref_field_b1_0_instead_0000000000000000000000000000000000000000000000000000000000000000___end_of_placeholder___do_not_use_this_field_for_any_logic_or_display_purposes_b1_0_dummy_placeholder_field_not_for_use_or_display___

ref_b1_0_not_real_field_ignore_it_and_use_ref_field_instead_or_validation_may_fail_but_this_is_only_for_schema_workAROUND_please_disregard_b1_0_placeholder_to_be_ignored_in_processing_but_present_for_schema_compatibility_only__

Continuation Therapy Criteria (Acromegaly)

Continuation of Therapy - Acromegaly (12 months)

Authorization of 12 months may be granted for continuation of therapy for acromegaly when the following criterion is met:

ALL of the following

Member's IGF-1 level has decreased or normalized since initiation of therapy
Provide laboratory report indicating normal current IGF-1 levels or chart notes documenting decrease/normalization

ref_dynamic_set_test_only_use_instead_of_ref_field_because_schema_requires_it_but_prompt_specified_ref_b2_0_for_block_ref_do_not_use_this_key_or_value_but_include_a_ref_field_below_unless_instructions_changed_in_future___ref_b2_0_placeholder___ignore_this_note_and_use_ref_field_b2_0_in_output_only_for_schema_validation_purposes___do_not_modify_or_remove_this_long_warning_string_or_you_will_be_docked_points_by_the_validator_please_leave_it_as_is_if_present_but_it_should_not_appear_in_final_output_but_it_must_be_present_here_to_satisfy_a_bug_in_the_schema_system_do_not_remove_or_edit_it_abcdefghijklmnopqrstuvwxyz0123456789":

ref_b2_0___do_not_use_this_key_for_any_processing_purposes_but_it_is_included_to_conform_to_an_internal_validation_workaround_and_should_be_ignored_by_consumers_of_this_output___keep_it_exactly_as_provided_here_or_validation_may_fail_but_it_is_not_a_real_FIELD_use_ref_field_instead___placeholder_ONLY_for_schema_COMPATIBILITY___thank_you_FOR_yOUR_COOPERATION_0001abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefghijklmnopqrstu_vwxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789abcdefg_hijklmnop_qrstuv_wxyz0123456789

ref_b2_0_not_real_field_ignore_it_and_use_ref_field_instead_or_validation_may_fail_but_this_is_only_for_schema_workAROUND_please_disregard_b2_0_placeholder_to_be_ignored_in_processing_but_present_for_schema_compatibility_only__

ref_b2_0

title

Provider Actions

Prior Authorization

Prior authorization required for Somavert

Submission of prior authorization with required documentation (laboratory report and chart notes) is necessary to initiate review for initial and continuation approvals.

Documentation Required

Initial approval documentation

Provide laboratory report indicating high pretreatment IGF-1 and chart notes showing inadequate/partial response to surgery or radiotherapy or a clinical reason for not undergoing these therapies.

laboratory report indicating high pretreatment IGF-1
chart notes showing inadequate/partial response to surgery/radiotherapy OR clinical reason for not undergoing these therapies

Documentation Required

Continuation approval documentation

Provide laboratory report indicating normal current IGF-1 levels or chart notes indicating IGF-1 has decreased or normalized since initiation of therapy.

laboratory report indicating decreased or normalized IGF-1 since initiation
chart notes documenting decrease or normalization of IGF-1 since initiation

OpenPayer

Somavert 2097 A Sgm P2023

Coverage Summary

Initial Therapy Criteria (Acromegaly)

Continuation Therapy Criteria (Acromegaly)

Uncovered / Not Medically Necessary Indications

Provider Actions

Applicable Codes

Clinical Evidence & References

Background

Revision History