CurrentUnitedHealthcarePolicy N/A

Neuromuscular Agents - Lupus Agents prior authorization form

This document is a prior authorization request form governing coverage review for neuromuscular/lupus agents (including voclosporin/Lupkynis) for UnitedHealthcare members; it directs providers what clinical and administrative information to submit for new or continuation therapy.

Policy Summary

PayerUnitedHealthcare

PolicyNeuromuscular Agents - Lupus Agents prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and fax the prior authorization form to 866-940-7328 with required clinical documentation for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursallow at least for review

866-940-7328fax number to submit form

800-310-6826phone number for questions

Voclosporinspecifically referenced drug

Coverage and Clinical Criteria

Prior authorization clinical criteria

Coverage review will consider the following documented criteria.

General requirements: Form fully completed and faxed; required documentation attached (chart notes, laboratory results showing active disease, functional assessments if applicable); prescriber specialty and signature provided.

See REQUIRED WITH THIS REQUEST

Acceptable diagnoses: Either lupus nephritis (active class III or IV, with or without class V, confirmed by renal biopsy) OR systemic lupus erythematosus with laboratory evidence of active disease and autoantibody-positive tests OR other specified diagnosis.

Provider must check appropriate diagnosis box and provide specifics if 'Other'.

Baseline and monitoring data: For lupus nephritis: provide baseline and current urinary protein-to-creatinine ratio and eGFR with dates; For SLE without renal measures: provide baseline assessment using validated SLE activity instruments (SIS, BILAG, SLAM, SLEDAI, PGA, SLICC Damage Index).

Policy Summary

PayerUnitedHealthcare

PolicyNeuromuscular Agents - Lupus Agents prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and fax the prior authorization form to 866-940-7328 with required clinical documentation for review.

SourceLink

On This Page

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Diagnosis and Clinical Values

Requested diagnosis code fieldICD-10

ICD-10 CODE

Place for diagnosis ICD-10 code as requested on form

eGFR — baseline and current values as entered on form

Baseline eGFRBaseline eGFR: __________ mL/min/m2 (enter value and date on form)

Current eGFR (if continuation)If a continuation, current eGFR: __________ mL/min/m2 (enter value and date on form)

Date fieldsDates for baseline and current eGFR must be provided on the form

Urinary protein to creatinine ratio — baseline and current values as entered on form

Baseline urinary protein-to-creatinine ratioBaseline: ___________ (enter value and date taken on form)

Current urinary protein-to-creatinine ratio (if continuation)If a continuation, current: ____________ (enter value and date taken on form)

Date fieldsDates for baseline and current urinary protein-to-creatinine ratio must be provided on the form

Actions Required from the Provider

Prior Authorization

Prior Authorization Required

Prior authorization required — complete and fax the form to 866-940-7328. Indicate whether the request is new or a continuation of therapy and allow at least 24 hours for review. If you have questions, call 800-310-6826.

Fax: 866-940-7328
Questions: 800-310-6826
Include whether request is new or continuation

Step Therapy

Prior Medication Trial Information

Provide prior medication trial information: list previous medications (name, strength, directions, dates of therapy) and reason for failure or discontinuation. For voclosporin (Lupkynis) requests, indicate whether belimumab was tried and found ineffective, not tolerated, or contraindicated — provide explanation if applicable.

Section D — Previous Medication Trials: Medication name, strength, directions, dates of therapy, reason for failure/discontinuation
Voclosporin-specific: Was belimumab used for lupus nephritis and ineffective/not tolerated/contraindicated? If yes, explain

Documentation Required

Required Documentation

Required documentation must be attached with the request: chart notes, laboratory results demonstrating active disease, and functional assessments (baseline and current if applicable). Include prescriber signature, prescriber specialty, and date.

Chart notes
Laboratory results showing active disease
Functional assessments — baseline and current if applicable (e.g., UPCR, eGFR, SLEDAI, BILAG, SIS, SLAM, PGA, SLICC)
Prescriber signature, specialty, and date

Denial Risk

Missing Required Documentation

Requests missing required attachments (chart notes, labs showing active disease, functional assessments, prescriber signature/specialty/date) may be delayed or denied.

Missing chart notes, labs, assessments, or signature may delay review or result in denial

Background and Scope

This prior authorization form applies to neuromuscular and lupus agents, including voclosporin (Lupkynis), for conditions such as lupus nephritis (active class III or IV, with or without class V, confirmed by renal biopsy) and systemic lupus erythematosus with evidence of active disease and autoantibody positivity. The form requests baseline and current measures relevant to renal involvement (urinary protein-to-creatinine ratio and eGFR) or validated SLE activity instruments, documents prior medication trials (including whether belimumab for lupus nephritis was ineffective, not tolerated, or contraindicated), and requires prescriber specialty or documented consultation for review.

Clinical Definitions

Lupus nephritis (as used here)

DefinitionLupus nephritis = active class III or IV, with or without class V, confirmed by renal biopsy.

Confirmation requiredProvider must check the Lupus nephritis box on the form and indicate biopsy confirmation.

ContextUsed as an acceptable diagnosis for prior authorization review for lupus agents.

SLE with active disease

DefinitionSLE with active disease = Systemic Lupus Erythematosus with laboratory results showing active disease and autoantibody-positive tests (e.g., ANA or anti-dsDNA).

Form requirementProvider must check the SLE with active disease box and attach laboratory results demonstrating active disease and positive autoantibodies.

Alternative assessmentsIf renal measures are not provided for SLE, baseline assessment with validated SLE activity instruments (SIS, BILAG, SLAM, SLEDAI, PGA, SLICC) may be used.