CurrentUnitedHealthcarePolicy N/A

Nc Aduhelm Pa Form

Prior authorization form used by UnitedHealthcare for Aduhelm (aducanumab) requests to document beneficiary, prescriber, drug, and clinical criteria required for approval. Captures diagnostic tests, age, exclusionary risks, monitoring and specialist involvement.

Policy Summary

PayerUnitedHealthcare

PolicyNc Aduhelm Pa Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the prior authorization form including beneficiary, prescriber, drug, and required clinical information and attestations (signature mandatory).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

12Required form items (beneficiary/prescriber/drug/clinical)

1Specialist requirement

2MRI monitoring timepoints

Coverage Summary

Coverage stance: covered_with_criteria. This prior authorization form documents the clinical criteria UnitedHealthcare requires for Aduhelm (aducanumab) approval, capturing beneficiary, prescriber, drug, and required clinical information including diagnostic confirmation of amyloid pathology, age requirement, baseline assessments, exclusionary risks, specialist involvement, and MRI monitoring timepoints.

Initial Therapy Criteria

Exclusions / Denial Criteria

Denial triggers / exclusionary risks: requests may be denied if the beneficiary has a history of or increased risk for ARIA-E (edema or sulcal effusions) or ARIA-H (microhemorrhage or superficial siderosis), or has hypersensitivity to any components of Aduhelm. Additional denial risk exists if required specialist involvement or documentation (prescriber attestation, diagnostic testing, and MRI monitoring attestations) is not provided.

Applicable Codes

No codes provided on formmixed

No codes listed

Provider Actions & Requirements

Policy Summary

PayerUnitedHealthcare

PolicyNc Aduhelm Pa Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the prior authorization form including beneficiary, prescriber, drug, and required clinical information and attestations (signature mandatory).

SourceLink

On This Page

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Documentation Required

Document diagnostic testing and baseline severity

Provider must document CDR global score of 0.5, objective cognitive impairment, MMSE or equivalent score, amyloid confirmation (PET or CSF), tests to rule out reversible causes, medication review, and baseline disease severity measure.

CDR global score of 0.5
Objective cognitive impairment at screening
MMSE score 24–30 (inclusive) or equivalent tool
Amyloid confirmation via PET or CSF
Tests to rule out reversible causes of dementia
Assessment including review of current medications as potential cause
Documented baseline disease severity using an objective measure/tool

Clinical Evidence & Definitions

This prior authorization form captures clinical criteria for Aduhelm for patients with mild cognitive impairment due to Alzheimer's disease or mild Alzheimer's dementia and documents objective diagnostic testing (CDR global score of 0.5, objective cognitive impairment, MMSE 24–30 or equivalent, and amyloid confirmation by PET or CSF).

The form also requires baseline assessments (age ≥50, medication review, tests to rule out reversible causes, recent brain MRI, and documented baseline disease severity), identifies exclusionary risks including ARIA and hypersensitivity, and specifies MRI monitoring prior to the 7th infusion (first 10 mg/kg) and 12th infusion (sixth 10 mg/kg).

ARIA-E: Amyloid related imaging abnormalities characterized by edema or sulcal effusions.

ARIA-H: Amyloid related imaging abnormalities characterized by hemosiderin deposition including microhemorrhage and superficial siderosis.

Background

Purpose: the PA form is intended to document that patients being considered for Aduhelm have MCI due to Alzheimer's disease or mild Alzheimer's dementia and to capture required diagnostic confirmation of amyloid pathology, baseline assessments, exclusionary risks (including ARIA), and MRI monitoring timepoints.

What it documents: beneficiary and prescriber information, objective diagnostic testing (CDR, cognitive testing, MMSE or equivalent, PET or CSF amyloid confirmation), tests to rule out reversible causes, medication review, recent MRI, prescriber attestation of baseline severity, exclusionary risks, specialist involvement, and scheduled MRIs prior to the 7th and 12th infusions.

OpenPayer