CurrentNeighborhood Health Plan of Rhode IslandPolicy 2097-A

Somavert (pegvisomant) for acromegaly

Policy governs prior authorization coverage criteria for Somavert (pegvisomant) for treatment of acromegaly, including required documentation for initial and continuation approvals and statement that non‑FDA indications are investigational.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySomavert (pegvisomant) for acromegaly

Policy CodePolicy 2097-A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization with required documentation: initial requests must include a pretreatment IGF-1 lab report and chart notes documenting inadequate/partial response to or ineligibility for surgery or radiotherapy; continuation requests must include current IGF-1 labs or chart notes showing improvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

1Covered Indications (acromegaly)

All othersNon‑covered indications

Coverage Summary

This policy governs prior authorization coverage criteria for Somavert (pegvisomant) for the treatment of acromegaly. Coverage is restricted to the FDA‑approved indication (acromegaly in patients with inadequate response to or inappropriate candidates for surgery or radiotherapy) and is covered with criteria. Authorization (initial and continuation) requires submission of specified laboratory and chart documentation to support use.

Thresholds and Quick Facts

Policy number2097-A

SubjectSomavert (pegvisomant) for acromegaly

Pretreatment IGF-1 (threshold)High for age and/or gender based on laboratory reference range

Continuation IGF-1 (threshold)Decreased or normalized since initiation of therapy (or current normal IGF-1)

Quick fact - IndicationCovered only for acromegaly in patients with inadequate response to or unsuitable for surgery/radiotherapy (FDA‑approved use)

Quick fact - DocumentationInitial: lab report showing high pretreatment IGF-1 + chart notes; Continuation: lab report showing decreased/normalized or current normal IGF-1 or chart notes

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization for Somavert (pegvisomant)

Providers must obtain prior authorization for Somavert (pegvisomant). Initial requests must include a laboratory report showing a high pretreatment IGF-1 level for age and/or gender and chart notes documenting an inadequate or partial response to surgery or radiotherapy or that surgery or radiotherapy are not an option. Continuation requests must include a laboratory report showing decreased or normalized IGF-1 since initiation of therapy or chart notes documenting improvement.

Documentation Required

Required documentation

Submit laboratory reports for IGF-1: pretreatment IGF-1 (high for age and/or gender) for initial requests; current IGF-1 demonstrating normalization or decrease for continuation. Also submit chart notes documenting either an inadequate or partial response to surgery or radiotherapy or documentation that surgery or radiotherapy are not an option.

Pretreatment IGF-1 lab report (initial)
Current IGF-1 lab report showing decreased or normalized level (continuation)
Chart notes documenting inadequate/partial response to surgery or radiotherapy (initial)
Chart notes documenting that surgery or radiotherapy are not an option (initial)

Clinical Evidence & References

Key evidence and guidance referenced:

• Somavert package insert, July 2023

• Katznelson L, Laws ER, Melmed S, et al. Acromegaly: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014;

• American Association of Clinical Endocrinologists Acromegaly Guidelines Task Force. Medical guidelines for clinical practice for the diagnosis and treatment of acromegaly - 2011 update. Endocr Pract. 2011.

Background

Somavert (pegvisomant) is indicated for treatment of acromegaly in patients who have had an inadequate response to surgery or radiotherapy, or for whom these therapies are not appropriate. The policy restricts coverage to this FDA‑approved indication and requires laboratory and chart documentation: for initial approval a high pretreatment IGF‑1 laboratory report and chart notes documenting inadequate/partial response to or ineligibility for surgery/radiotherapy; for continuation a laboratory report showing IGF‑1 has decreased or normalized since starting therapy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySomavert (pegvisomant) for acromegaly

Policy CodePolicy 2097-A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Somavert (pegvisomant) for acromegaly

Coverage Summary

Initial Therapy Criteria (Acromegaly)

Continuation Therapy Criteria (Acromegaly)

Non‑covered / Investigational Indications

Provider Actions & Documentation Requirements

Applicable Codes

Clinical Evidence & References

Background

Revision History