CurrentUnitedHealthcarePolicy N/A

Prior Authorization Request Form for Cytokine and CAM Medications

A multi-diagnosis prior authorization (PA) form to request coverage of cytokine and CAM medications for multiple inflammatory and autoimmune conditions. The form collects patient, provider, medication, trial history, diagnosis-specific clinical criteria, and documentation requirements for initial and continuation therapy decisions.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Request Form for Cytokine and CAM Medications

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionComplete the entire PA form and fax chart notes and baseline assessments to 866-940-7328 (allow at least 24 hours for review).

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is an informational multi-diagnosis PA form.

10Diagnoses covered by form

24-40Question range for diagnoses

Policy overview and scope

This is a multipurpose prior authorization request form to request coverage of cytokine and CAM medications for multiple inflammatory and autoimmune conditions. The form collects patient demographics, provider and pharmacy information, medication name/strength/directions/quantity and date of request, indication and prescriber specialty or consult, current weight and date, prior medication trial history (drug name and duration), whether the request is a continuation of therapy, and documentation of disease stability or positive clinical response. Diagnosis-specific sections request clinical criteria, minimum trial durations, baseline assessments, and continuation criteria; chart notes with prescriber signature, specialty, and date are required.

Form summary

Diagnoses covered by form10

Question range for diagnoses24-40

Coverage stanceinformational

StatusCURRENT

SubjectPrior Authorization Request Form for Cytokine and CAM Medications

Diagnosis-specific criteria (initial and continuation)

General Prior Authorization Questions

Complete all applicable sections; required documentation and chart notes must be submitted.

ALL of the following

Patient/Request Information: Complete patient demographics, provider information, pharmacy information, medication name and strength, directions, quantity/days supply, date of request, reference number, MAS, ProviderOne ID.
Continuation: Indicate if request is continuation of therapy and if clinical documentation demonstrates disease stability or positive clinical response.
Prescriber Specialty: Indicate prescriber specialty or consult (Allergist, Dermatologist, Gastroenterologist, Immunologist, Rheumatologist, Other).
Combination Therapy: Indicate if medication will be used in combination with another Cytokine and CAM medication.
Preferred Drug Trials: If request is non-preferred, provide trials of preferred Cytokine and CAM medications on the Apple Health Preferred Drug List with durations or explain why not tried.
Weight: Provide patient's current weight and date taken.
Chart Notes and Signature: Attach chart notes; prescriber signature, specialty, and date required.

Alopecia areata - Coverage Criteria Questions

For diagnosis of Alopecia areata complete ALL applicable questions 7-10.

ALL of the following

Episode Duration: Current episode of alopecia areata lasting more than 6 months.> 6 months
Question 7
Severity (SALT): History of 250% scalp hair loss (SALT score >50%).SALT >50%
Question 8
Prior therapy failure/contraindication/intolerance
- Topical high-potency corticosteroids:

Ankylosing Spondylitis / Non-radiographic axial spondyloarthritis

For diagnosis complete ALL applicable questions 11-15.

ALL of the following

Disease activity score
- BASDAI score of at least 4>= 4
- ASDAS score of at least 2.1>= 2.1
NSAID trials: Treatment with at least two different NSAIDs that were ineffective, contraindicated or not tolerated (minimum trial of four weeks each).minimum 4 weeks each
Question 12

Atopic Dermatitis

For diagnosis complete ALL applicable questions 16-20.

ALL of the following

Severity / involvement
- BSA involvement of at least 10%>= 10% BSA
- Sensitive areas: Involvement of sensitive skin areas (hands, feet, face, neck, genitalia, intertriginous areas)
- Severity scale: Severe chronic atopic dermatitis by disease severity scale (IGA ≥3, EASI, POEM, etc.)IGA >=3

Crohn's Disease

For diagnosis complete ALL applicable questions 21-23.

ALL of the following

Conventional therapy failures
- Oral corticosteroids used short-term to induce remission or alleviate flare symptoms
- Immunomodulatory agent (e.g., methotrexate, azathioprine, 6-mercaptopurine) ineffective, contraindicated, or not tolerated (minimum trial of 12 weeks)minimum 12 weeks
High-risk disease documentation: Documentation of high-risk disease (e.g., symptoms despite conventional therapy, obstruction, abscess, stricture, phlegmon, fistulas, resection, extensive bowel involvement, early age of onset, growth retardation, CDAI ≥450, Harvey-Bradshaw index >7).CDAI >=450; Harvey-Bradshaw >7

Plaque Psoriasis

For diagnosis complete ALL applicable questions 24-28.

ALL of the following

Duration: Ongoing disease for greater than 6 months.> 6 months
Question 24
Location / extent
- 10% BSA: Disease affects at least 10% body surface area>= 10% BSA
- Special sites: Disease affects face, ears, hands, feet, or genitalia

Polyarticular Juvenile Idiopathic Arthritis (poly JIA)

For diagnosis complete ALL applicable questions 29-30.

ALL of the following

DMARD trial: Treatment with at least one non-Cytokine and CAM DMARD (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine) ineffective, contraindicated, or not tolerated (minimum trial of 3 months).minimum 3 months
Question 29
Continuation: For continuation: documentation demonstrating disease stability or a positive clinical response (improvement in joint pain, swelling, ADLs, reduction in flares).
Question 30

Psoriatic Arthritis (PsA)

For diagnosis complete ALL applicable questions 31-34.

ALL of the following

DMARD trial: Has patient had treatment with at least one non-Cytokine and CAM DMARD that has been ineffective, contraindicated or not tolerated (minimum trial of 3 months)?minimum 3 months
Question 31
Active severe disease: Presence of active, severe disease indicated by provider assessment.
Question 32
Severe disease indicators
- Erosive disease

Rheumatoid Arthritis (RA)

For diagnosis complete ALL applicable questions 35-37.

ALL of the following

Baseline assessments submitted (DAS28-CRP/ESR, SDAI, CDAI, RAPID3, PAS II).
Question 35
DMARD trial: Treatment with at least one non-Cytokine and CAM DMARD ineffective, contraindicated, or not tolerated (minimum trial of 3 months).minimum 3 months
Question 36
Continuation: For continuation: documentation demonstrating disease stability or a positive clinical response (improvement in DAS28, SDAI, CDAI, RAPID3, PAS II).
Question 37

Ulcerative Colitis (UC)

For diagnosis complete ALL applicable questions 38-40.

ALL of the following

Baseline assessments submitted (stool frequency, endoscopy results, rectal bleeding, disease activity scoring tool).
Question 38
Conventional therapy trial: Treatment with conventional therapy (systemic corticosteroids, azathioprine, mesalamine, sulfasalazine) ineffective, contraindicated, or not tolerated (minimum trial of 12 weeks).minimum 12 weeks
Question 39
Continuation: For continuation: documentation demonstrating disease stability or a positive clinical response (decreased stool frequency, decreased rectal bleeding, improved endoscopic activity, corticosteroid taper/discontinuation, or improved disease activity score).
Question 40

What providers must do

Documentation Required

Attach chart notes and baseline assessments

Chart notes are required with the request. Include the prescriber signature, prescriber specialty, date, and relevant baseline assessments as applicable to the diagnosis (examples: BSA, PASI, PGA, DAS28, BASDAI, ASDAS, CDAI).

Prior Authorization

Fax prior authorization form

Complete the entire prior authorization form and fax it to 866-940-7328. Allow at least 24 hours for review. For questions, call 800-310-6826.

Documentation Required

Document prior treatment trials

Provide details of prior medication trials including each drug name and duration, demonstrating failure, contraindication, or intolerance. Include trials of preferred Cytokine and CAM agents on the Apple Health Preferred Drug List when applicable.

Documentation Required

Continuation therapy evidence

For continuation requests, submit documentation demonstrating disease stability or a positive clinical response using diagnosis-specific metrics; examples and required measures are provided in the form (e.g., decrease in BASDAI or ASDAS, improvement in BSA/PASI/PGA, decrease in CDAI, improvement in endoscopic activity, steroid taper/discontinuation).

Key numeric thresholds and required baseline assessments

Key thresholds and minimum trials

Duration of alopecia areata episode> 6 months

SALT (Severity of Alopecia Tool)>50% scalp hair loss

BASDAI>= 4

ASDAS>= 2.1

Atopic dermatitis BSA>= 10% BSA

Dupilumab trialminimum 16 weeks

Topical therapy trial (AD)minimum 28 days each

Phototherapy trial (psoriasis)minimum 12 weeks

Non-cytokine DMARD trial (various indications)minimum 3 months

Immunomodulator trial (Crohn's)minimum 12 weeks

Conventional therapy trial (Ulcerative Colitis)minimum 12 weeks

NSAID trial (axial spondyloarthritis)minimum 4 weeks

Examples of baseline assessments that must be submitted as applicable to the diagnosis include: BSA, PASI, PGA, itch numeric rating scale (Plaque Psoriasis), DAS28 (CRP/ESR), SDAI, CDAI, RAPID3, PAS II (Rheumatoid Arthritis), BASDAI, ASDAS (Ankylosing Spondylitis/non-radiographic axial spondyloarthritis), and for gastrointestinal disease stool frequency, endoscopy results, rectal bleeding, and disease activity scoring tools (Ulcerative Colitis). Chart notes must include these baseline assessments where indicated.

Document changes

No revision history entries were provided in the brief.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Request Form for Cytokine and CAM Medications

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionComplete the entire PA form and fax chart notes and baseline assessments to 866-940-7328 (allow at least 24 hours for review).

On This Page

High-potency topical corticosteroids (minimum trial of 6 weeks)

Intralesional corticosteroids (minimum trial of 6 weeks)minimum 6 weeks

Systemic therapy (e.g., oral corticosteroids, methotrexate, cyclosporine) (minimum trial of 6 weeks)minimum 6 weeks

Continuation: For continuation: documentation demonstrating a positive clinical response.

Question 10

Disease manifestation

Axial disease
Peripheral arthritis

DMARD trial: Treatment with at least one non-Cytokine and CAM DMARD that was ineffective, contraindicated or not tolerated (minimum trial of 3 months).minimum 3 months

Question 14

Continuation: For continuation: documentation demonstrating disease stability or a positive clinical response (e.g., decrease in BASDAI or ASDAS).

Question 15

Functional impact

ADLs: Functional impairment in activities of daily living (ADLs)
Infections: Skin infections
Sleep disturbances
Other (specify)

Topical therapy failures or contraindications

Topical calcineurin inhibitors: History of failure to topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) (minimum 28 days each)minimum 28 days
Topical PDE-4 inhibitors: History of failure to topical PDE-4 inhibitors (e.g., crisaborole) (minimum 28 days each)minimum 28 days
All contraindicated: All are contraindicated or clinically inappropriate (explain)

Dupilumab trial: Dupilumab (Dupixent) ineffective, contraindicated, or not tolerated (minimum trial of 16 weeks).minimum 16 weeks

Question 19

Continuation response metrics

BSA improvement: Reduction in BSA involvement of at least 20%>= 20% reduction
IGA: Achieved or maintained IGA 0 or 1IGA 0 or 1
EASI: Decrease in EASI score of at least 50%>= 50% decrease
Functional improvement: Improvement in functional impairment (ADLs, infections, sleep)

Continuation: For continuation: documentation demonstrating disease stability or positive clinical response (e.g., improvement in endoscopic activity, corticosteroid taper/discontinuation, reduction in liquid stools, decreased abdominal pain, decreased CDAI/Harvey-Bradshaw).

Question 23

Baseline assessments submitted (BSA, PASI, PGA, itch numeric rating scale, etc.).

Question 26

Prior therapy failures

Phototherapy (UVB or PUVA) failed (minimum trial of 12 weeks)minimum 12 weeks
Non-cytokine DMARD: Treatment with at least one non-Cytokine and CAM DMARD failed (minimum trial of 12 weeks)minimum 12 weeks

Continuation: For continuation: documentation demonstrating disease stability or a positive clinical response (improvement in BSA, PASI, PGA, itch numeric rating scale).

Question 28

Elevated CRP/ESR: Elevated CRP or ESR

Long-term damage interfering with function (e.g., joint deformities, vision loss)

Major impairment of quality of life due to high disease activity at many sites or functionally limiting arthritis at a few sites (including dactylitis, enthesitis)

Continuation: For continuation: documentation has been submitted demonstrating disease stability or a positive clinical response (improvement in joint pain, swelling, ADLs, reduction in flares).

Question 34