CurrentUnitedHealthcarePolicy N/A

Signifor (pasireotide) prior authorization

Defines UnitedHealthcare prior authorization and reauthorization requirements for Signifor (pasireotide) for treatment of adult Cushing's disease when surgery is not an option or not curative; applies to UnitedHealthcare pharmacy benefit management processes.

Policy Summary

PayerUnitedHealthcare

PolicySignifor (pasireotide) prior authorization

Policy CodePolicy N/A

Change TypeRevised initial authorization duration

Effective DateDec 1, 2025

Next Review DateOct 1, 2025

Key ActionSubmit documentation of endogenous Cushing's disease and surgery status for initial authorization; approvals issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

Updated initial authorization duration to 12 months.

12 moinitial authorization duration

12 moreauthorization duration

Adult Cushing'sindication

Prior Authprogram type

NCapplicable state

Policy Summary

PayerUnitedHealthcare

PolicySignifor (pasireotide) prior authorization

Policy CodePolicy N/A

Change TypeRevised initial authorization duration

Effective DateDec 1, 2025

Next Review DateOct 1, 2025

Key ActionSubmit documentation of endogenous Cushing's disease and surgery status for initial authorization; approvals issued for 12 months.

SourceLink

On This Page

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Initial Therapy

Covered when ALL of the following are met:

Initial Authorization: 1) Diagnosis of endogenous Cushing's disease (hypercortisolism not due to chronic high‑dose glucocorticoids).

Authorization issued for 12 months

Surgery status (one of the following must be met)

Options: (a) Pituitary surgery has not been curative
(b) Patient is not a candidate for pituitary surgery

Continuation Therapy / Reauthorization

Covered when ALL of the following are met:

Reauthorization: Documentation of positive clinical response to Signifor therapy.

Authorization issued for 12 months

Treatment of hypercortisolism resulting from chronic administration of high-dose glucocorticoids (i.e., non-endogenous Cushing's) is excluded from this indication. Coverage applies only to endogenous Cushing's disease (hypercortisolism not caused by chronic high‑dose glucocorticoid therapy).

Provider Requirements, Documentation, and Operational Rules

Prior Authorization

Prior Authorization Required for Initiation

Initial authorization for Signifor requires documentation of endogenous Cushing's disease and one of the listed pituitary surgery criteria. Authorization will be issued for 12 months.

Diagnosis: endogenous Cushing's disease (hypercortisolism not due to chronic high-dose glucocorticoids)
One of the following: pituitary surgery was not curative OR patient is not a candidate for pituitary surgery
Initial approvals issued for 12 months

Documentation Required

Reauthorization Documentation Required

Reauthorization requires documentation of a positive clinical response to therapy. Approvals for continuation will be issued for 12 months. State mandates, federal requirements, and member-specific benefit plan coverage may affect applicability.

Documentation of positive clinical response to Signifor
Reauthorization approvals issued for 12 months
Coverage may be impacted by state mandates, federal requirements, and member-specific benefit plans

Billing Rule

Automated Processing and Supply Limits

UnitedHealthcare may use automated approval and re-approval processes that rely on prior claims/medication history, diagnosis codes, and claim logic. These operational processes can approve initial or continued therapy without additional clinical documentation when criteria are met. Supply limits may apply.

Automated approvals may be granted based on prior claim/medication history, ICD-10 diagnosis codes, and claim logic
Use of automated approval/reauthorization varies by program and therapeutic class
Supply limits may be enforced

Denial Risk

Potential Denial Triggers

Missing required documentation (e.g., absence of an endogenous Cushing's diagnosis or lack of documentation regarding prior pituitary surgery or surgical candidacy) may result in denial of the request.

Denial risk if endogenous Cushing's diagnosis is not documented
Denial risk if documentation of prior pituitary surgery status or surgical candidacy is missing

Definitions

Endogenous Cushing's disease — definition

DefinitionEndogenous Cushing's disease: hypercortisolism originating from an internal (endogenous) source — e.g., pituitary tumor (Cushing's disease) — rather than from chronic administration of high‑dose glucocorticoids.

Distinguishing featureNot caused by chronic exogenous glucocorticoid therapy — treatment of hypercortisolism due to chronic high‑dose glucocorticoids is excluded from this indication.

Typical causePituitary corticotroph adenoma leading to excess ACTH (pituitary‑origin Cushing's disease).

Relevance to coveragePolicy covers Signifor for adult patients with endogenous Cushing's disease when pituitary surgery is not an option or has not been curative.

Clinical implication for authorizationRequests must document a diagnosis of endogenous Cushing's disease (i.e., hypercortisolism not due to chronic high‑dose glucocorticoids); failure to do so may lead to denial.

OpenPayer

Signifor (pasireotide) prior authorization

Coverage Criteria for Signifor (pasireotide)

Provider Requirements, Documentation, and Operational Rules

Background on Signifor (pasireotide)

Definitions