CurrentUnitedHealthcarePolicy N/A

Chronic GI Motility Agents - Washington Prior Authorization Request Form

This Washington-specific prior authorization form governs submissions for chronic gastrointestinal motility agents, detailing required documentation, prior therapy history, and administrative submission instructions.

Policy Summary

PayerUnitedHealthcare

PolicyChronic GI Motility Agents - Washington Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form to 866-940-7328 and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

866-940-7328fax number to submit form

24 hoursallow at least time for review

800-310-6826phone number for questions

Washingtonapplicable state

Approval Criteria for Chronic GI Motility Agents

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Provider indicates specific diagnosis and supplies ICD-10 code (select one: IBS-C, IBS-D, CIC, advanced/terminal illness receiving palliative care, or opioid-induced constipation).

Refer to Section A of the form for diagnosis selection and ICD-10 code.

Known or suspected gastrointestinal obstruction has been ruled out.

Provider attests patient does not have a history of any contraindications to the requested medication.

Prior therapy requirement (by indication)

For IBS-D agents (Lotronex, Viberzi)
- History of failure, contraindication, or intolerance to a ≥ 2-week trial of two conventional therapies (examples: antidiarrheals such as loperamide; antispasmodics such as dicyclomine or hyoscyamine; antibiotics; antidepressants such as amitriptyline or sertraline; bile acid sequestrants such as cholestyramine or colestipol).
For CIC and related agents (Linzess, Amitiza, Trulance, Relistor, Symproic, Movantik)
- History of failure, contraindication, or intolerance to a ≥ 2-week trial of two conventional therapies (examples: bulk-forming laxatives such as psyllium; stool softeners such as docusate sodium; osmolar agents such as lactulose; stimulant laxatives such as sennosides; polyethylene glycol such as Miralax).

For continuation requests: document therapy start date and provide documentation of positive clinical symptomatic improvement to therapy.

Complete Section D listing prior medication trials with dates and reasons for failure or discontinuation.

Form must be fully completed and faxed to the listed fax number; allow at least 24 hours for review and processing.

See provider submission instructions on the form.

Diagnosis and Therapy Coding Requirements

Diagnosis codingICD-10

ICD-10 code to be supplied by provider

inv-03: Prior therapy requirement

RequirementHistory of failure, contraindication or intolerance to a ≥ 2-week trial of two conventional therapies

Scope by agent group for IBS-D (Lotronex, Viberzi)Conventional therapies include antidiarrheals (e.g., loperamide), antispasmodics (e.g., dicyclomine, hyoscyamine), antibiotics, antidepressants (e.g., amitriptyline, sertraline), and bile acid sequestrants (e.g., cholestyramine, colestipol)

Scope by agent group for CIC and related agents (Linzess, Amitiza, Trulance, Relistor, Symproic, Movantik)Conventional therapies include bulk-forming laxatives (e.g., psyllium), stool softeners (e.g., docusate sodium), osmolar agents (e.g., lactulose), stimulant laxatives (e.g., sennoside), and polyethylene glycol (e.g., Miralax)

Prior Authorization Submission Requirements

Prior Authorization

Submit fully completed prior authorization form by fax and include required clinical details

Complete the Washington Chronic GI Motility Agents prior authorization request form and fax the fully completed form to 866-940-7328; allow at least 24 hours for review. Include member and provider information, medication details (name, strength, directions, quantity), diagnosis with ICD-10 code, pregnancy status, prior medication trials (with dates and reasons for failure/discontinuation), and provider attestation regarding contraindications. For continuation requests, indicate continuation, provide the therapy start date, and include documentation of documented positive clinical symptomatic improvement.

Fax completed form to 866-940-7328 and allow at least 24 hours for review.
Provide member details (name, member ID, contact, DOB, allergies) and indicate if hospitalized or recently discharged.
Provide provider details (name, NPI, specialty, phone/fax) and office contact.
List medication name, strength, directions, quantity, and ICD-10 diagnosis code.
Complete Section D listing prior medication trials with dates and reasons for failure/discontinuation.
Attest that GI obstruction has been ruled out and that the patient has no history of contraindications to the requested medication.
For continuation requests, list therapy start date and document positive clinical symptomatic improvement.

Indications and Examples of Conventional Therapies

inv-05: Indications listed on form

IBS-CIrritable bowel syndrome with constipation

IBS-DSevere irritable bowel syndrome with diarrhea

CICChronic idiopathic constipation

Advanced illness/palliative careAdvanced illness (or terminal illness) receiving palliative care

OICOpioid-induced constipation with chronic non-cancer pain

inv-06: Examples of conventional therapies

AntidiarrhealsExamples: loperamide

AntispasmodicsExamples: dicyclomine, hyoscyamine

AntibioticsListed as a conventional therapy option for IBS-D

AntidepressantsExamples: amitriptyline, sertraline

Bile acid sequestrantsExamples: cholestyramine, colestipol

Bulk-forming laxativesExamples: psyllium

Osmolar agentsExamples: lactulose

Stimulant laxativesExamples: sennoside

Stool softenersExamples: docusate sodium

Polyethylene glycolExamples: Miralax