CurrentUnitedHealthcarePolicy N/A

NMOSD Prior Authorization Request Form — Coverage Criteria and Provider Requirements

This document is a prior authorization (PA) request form used by providers to request coverage for medications for Neuromyelitis Optica Spectrum Disorder (NMOSD) for UnitedHealthcare beneficiaries; it specifies required beneficiary, prescriber and clinical screening information required to process PA requests.

Policy Summary

PayerUnitedHealthcare

PolicyNMOSD Prior Authorization Request Form — Coverage Criteria and Provider Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including beneficiary and prescriber information, drug details, NMOSD clinical screening questions, and the prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6required beneficiary/prescriber/drug/clinical fields

5clinical screening questions for NMOSD

1mandatory prescriber signature

Coverage and Authorization Criteria

Initial PA submission criteria

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Completed administrative fields: Beneficiary name, beneficiary ID number, date of birth, and gender; prescriber NPI and requester contact information (name and phone); drug name, strength, quantity per 30 days, and requested length of therapy.

Fields shown in chunks 0-2

Clinical NMOSD confirmation: Affirmative documentation that the beneficiary has a diagnosis of Neuromyelitis Optica Spectrum Disorder.

Chunk 3 question 1

AQP4 antibody status: Documentation of whether the beneficiary is anti-aquaporin-4 (AQP4) antibody positive.

Chunk 3 question 2

Age requirement: Documentation that the beneficiary is 18 years of age or older.>=18 years

Chunk 3 question 3

Concurrent biologic use: Statement that the beneficiary is not currently on another injectable biologic immunomodulator.

Chunk 3 question 4

Infection screening: Confirmation that the beneficiary has been considered/screened for latent tuberculosis infection and tested for Hepatitis B surface antigen (SAG) and core antibody (Core Ab).

Chunk 3 questions 5-6

Prescriber attestation: Mandatory prescriber signature and date attesting that the information provided is accurate and complete.signed

Chunk 4

Required Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for NMOSD-related medications. The prior authorization request must include beneficiary and prescriber information, specific requested drug details, and completed clinical screening questions to assess diagnosis and eligibility.

Include beneficiary name, ID number, date of birth, and gender
Include prescribing provider NPI and requester contact name/phone
Specify drug name, strength, quantity per 30 days, and length of therapy
Complete NMOSD clinical screening questions (diagnosis, AQP4 antibody status, age, concurrent biologic use, TB and hepatitis screening)

Step Therapy

Step Therapy / Concurrent Biologic Use

Step therapy is not specified for NMOSD agents in this form, but the request must state whether the beneficiary is currently receiving another injectable biologic immunomodulator. Concurrent use of another injectable biologic may affect approval.

Question on form: Is the beneficiary not on another injectable biologic immunomodulator? (Yes/No)

Documentation Required

Required Documentation Elements

Provide complete documentation with the prior authorization submission. Missing required elements may delay processing or lead to denial.

Beneficiary: last name, first name, beneficiary ID number, date of birth, gender
Prescriber: prescribing provider NPI number, requester contact name and phone number (with extension if applicable)
Drug: drug name, strength, quantity per 30 days, length of therapy (select or specify)
Clinical screening: confirmation of NMOSD diagnosis, AQP4 antibody status, beneficiary age (>=18), TB latent infection screening, Hepatitis B surface antigen and core antibody testing
Prescriber signature and date (mandatory)

Denial Risk

Incomplete Form May Trigger Denial

Incomplete or unsigned forms may be returned, delayed, or denied. The prescriber's signature is mandatory and certifies the information is accurate and complete.

Missing prescriber signature or incomplete clinical answers may result in denial or processing delay
Ensure all beneficiary identifiers, prescriber NPI/contact, drug details, and screening responses are completed before submission
Pharmacy PA Call Center for assistance: 1-855-258-1593

Clinical Background

Neuromyelitis Optica Spectrum Disorder (NMOSD) is an inflammatory neurological disorder commonly evaluated in the presence of AQP4 antibody positivity. This PA form requires documentation confirming a diagnosis of NMOSD and whether the beneficiary is anti-aquaporin-4 (AQP4) antibody positive, and it also collects key baseline screening information — including age (must document if the beneficiary is 18 years of age or older), current use of another injectable biologic immunomodulator, latent tuberculosis screening, and Hepatitis B surface antigen and core antibody testing — to inform safe initiation of NMOSD-specific therapies.

Terms and Definitions

AQP4 antibody positive — definition and diagnostic role

DefinitionPresence of anti-aquaporin-4 (AQP4) antibodies — a biomarker commonly used to support a diagnosis of Neuromyelitis Optica Spectrum Disorder (NMOSD).

Role in diagnosisUsed as a key clinical screening item on the NMOSD prior authorization form to document seropositivity status.

Form requirementPA form explicitly asks: 'Is the beneficiary anti-aquaporin-4 (AQP4) antibody positive?' — providers must document Yes or No.

Implication for coverage reviewDocumentation of AQP4 antibody status is required as part of initial PA submission criteria for NMOSD therapies.

Injectable biologic immunomodulator — definition and current-use question

DefinitionAn injectable biologic immunomodulator is a biologic medication administered by injection that modulates the immune system.

Form questionPA form asks: 'Is the beneficiary not on another injectable biologic immunomodulator?' — providers must answer Yes or No.

Purpose on formUsed to identify concurrent biologic use; no step-therapy sequencing or failure requirements are specified on the form.

Provider actionProviders must state current use (Yes/No) of other injectable biologic immunomodulators as part of the required clinical screening information.

Policy Revision History

2026-06-11document_statusLatest

Current prior authorization request form for NMOSD in use; requires completed beneficiary, prescriber, drug, and clinical screening fields including AQP4 status, age, infection screening, and prescriber signature.

form_content

Form includes beneficiary identification fields (name, ID, DOB, gender), prescriber NPI and contact, and drug information (name, strength, quantity per 30 days, length of therapy options).

clinical_questions

NMOSD-specific clinical screening questions ask about diagnosis confirmation, AQP4 antibody status, age ≥18, concurrent injectable biologic use, latent TB screening, and Hepatitis B testing.