CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Antifungal therapy authorization (unspecified agent)

Defines clinical criteria for prior authorization of an antifungal agent for various invasive fungal infections and prophylaxis in high-risk hematologic patients, including age limits, diagnostic requirements, and prior therapy failure requirements. Also specifies coverage duration.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAntifungal therapy authorization (unspecified agent)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionAn authorization may be granted only when the listed age and diagnosis criteria (including documented prior antifungal failures where specified) are met.

POLICY UPDATE CHANGES

No material clinical or coverage changes; policy remains current with existing approval criteria.

5Distinct covered indications listed

>=2Minimum patient age (years)

0 monthsCoverage duration

Coverage Summary

Scope: Defines clinical criteria for prior authorization of an antifungal agent for various invasive fungal infections and prophylaxis in high-risk hematologic patients. Coverage is covered_with_criteria for the subject: Antifungal therapy authorization (unspecified agent).

Criteria for Approval

An authorization may be granted when all the following criteria are met:

ALL of the following

ANY of the following diagnoses (one required)
- ALL of the following
  - Patient is 2 years or older
  - Documented diagnosis of a serious infection caused by scedosporium and fusarium species
- ALL of the following
  - Patient is 2 years or older
  - Documented diagnosis of an invasive aspergillus infection
- ALL of the following
  - Patient is 2 years or older
  - Documented diagnosis of esophageal candidiasis or oropharyngeal candidiasis
  - Documented failure of or clinical inappropriateness to fluconazole and itraconazole
- ALL of the following
  - Patient is 2 years or older
  - Documented diagnosis of prevention of invasive aspergillus and candida fungal infections
  - Documentation of hematologic malignancy with neutropenia, hematopoietic stem cell transplant, or graft-versus-host disease
- ALL of the following
  - Patient is 2 years or older
  - Documented diagnosis of candidemia and disseminated candidiasis infections
  - Documented failure of or clinical inappropriateness to oral fluconazole

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Provider Actions / Authorization Requirements

Prior Authorization

Authorization required

An authorization may be granted only when the listed age and diagnosis criteria (including documented prior antifungal failures where specified) are met.

Documentation Required

Document prior therapy failure or inappropriateness

For esophageal/oropharyngeal candidiasis and candidemia/disseminated candidiasis, document failure of or clinical inappropriateness to fluconazole (and itraconazole for oropharyngeal/esophageal cases) in the medical record submitted for authorization.

Background

This policy covers clinical scenarios including authorization for treatment of invasive fungal infections such as those caused by Scedosporium and Fusarium species, and invasive Aspergillus infections when the listed criteria are met.

It also covers prophylaxis and treatment in high-risk hematologic patients — specifically for prevention of invasive Aspergillus and Candida infections in patients with hematologic malignancy with neutropenia, hematopoietic stem cell transplant, or graft-versus-host disease — and for esophageal/oropharyngeal candidiasis and candidemia/disseminated candidiasis when there is documented failure of or clinical inappropriateness to azole therapy (fluconazole; itraconazole as applicable).