CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Gattex (teduglutide) for short bowel syndrome — Coverage Criteria

Coverage and authorization criteria for Gattex (teduglutide) for members with short bowel syndrome dependent on parenteral support; applies to the payer's Medicaid population.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGattex (teduglutide) for short bowel syndrome — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2022

Next Review DateN/A

Key ActionRequest initial authorization for 6 months when documentation shows member ≥1 year, diagnosis of SBS, gastroenterology involvement, dose ≤0.05 mg/kg/day, and required parenteral support dependence criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 moinitial authorization duration

0.05 mg/kgmax dose (once daily)

1 / 30dqty limit (5 mg kit)

≥1 yrminimum age

Coverage Criteria for Gattex (teduglutide)

Initial Therapy

Covered when ALL of the following are met for treatment of short bowel syndrome:

SBS initial authorization criteria: Member is >= 1 year of age

Diagnosis: Member has a diagnosis of short bowel syndrome (SBS)

IBD/fistula remission: If member has inflammatory bowel disease (IBD) and/or fistulas, they must be in clinical remission for at least 12 weeks12 weeks

Prescriber: Medication is prescribed by or in consultation with a gastroenterologist

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGattex (teduglutide) for short bowel syndrome — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2022

Next Review DateN/A

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.

Continuation / Reauthorization

Reauthorization covered when ANY of the following are met:

Continued dependence with improvement: Member remains dependent on parenteral nutrition and/or IV fluids and requirement for parenteral support has decreased by at least 20% from baseline while on therapy>=20% reduction from baseline

6-month authorization

Weaned off while on therapy: Member was previously dependent on parenteral nutrition/IV fluids and has been able to wean off requirement while on therapy

6-month authorization

Provider Actions, Documentation & Limits

Prior Authorization

Initial 6-month authorization

Authorization of 6 months may be granted when all specified criteria are met: member is ≥ 1 year of age; diagnosis of short bowel syndrome (SBS); medication prescribed by or in consultation with a gastroenterologist; dose does not exceed 0.05 mg/kg/day once daily; and documentation of parenteral nutrition/IV fluid dependence as specified below.

Initial authorization: 6 months
Dose limit: ≤ 0.05 mg/kg/day once daily

Prior Authorization

Reauthorization 6 months

Reauthorization may be granted for 6 months when documentation shows continued dependence on parenteral nutrition and/or intravenous fluids with the required frequency/duration, or documentation shows the member has weaned off parenteral support while on therapy when applicable.

Reauthorization: 6 months
Documentation must show ongoing dependence or successful weaning as described in policy

Note

Provider alert: ensure required clinical and administrative documentation is submitted with the prior authorization request to avoid delays or denial.

Documentation Required

Required documentation

Required documentation includes confirmation of age (≥ 1 year), diagnosis of short bowel syndrome (SBS), evidence of gastroenterologist prescribing or consultation, and documentation of parenteral nutrition/IV fluid dependence meeting policy thresholds.

Age documented: ≥ 1 year
SBS diagnosis documented
Gastroenterologist involvement documented
Parenteral nutrition/IV fluids dependence documented per policy

Documentation Required

IBD/fistula remission documentation

For members with inflammatory bowel disease (IBD) and/or fistulas, documentation of clinical remission for at least 12 weeks is required prior to approval.

IBD/fistula: clinical remission ≥ 12 weeks

Denial Risk

Indication restrictions

Use for indications other than FDA-approved short bowel syndrome (SBS) is considered experimental/investigational and is not medically necessary.

Non‑SBS indications: not medically necessary

Denial Risk

Dose limit

Dose exceeding 0.05 mg/kg/day once daily may trigger denial; ensure weight-based dosing is documented.

Dose limit: 0.05 mg/kg/day once daily

OpenPayer

Gattex (teduglutide) for short bowel syndrome — Coverage Criteria

Coverage Criteria for Gattex (teduglutide)

Coding and Parenteral Nutrition Criteria

Provider Actions, Documentation & Limits

Background

Definitions