CurrentUnitedHealthcarePolicy N/A

Austedo (deutetrabenazine) prior authorization for movement disorders

Defines the prior authorization form and clinical documentation requirements for UnitedHealthcare coverage of Austedo for movement disorders (tardive dyskinesia and Huntington's disease chorea) for beneficiaries in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicyAustedo (deutetrabenazine) prior authorization for movement disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the NC Pharmacy Prior Approval Request form including beneficiary and prescriber information, indication-specific questions, required baseline AIMS or ESRS documentation, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2indications

≥18min age

AIMS/ESRSbaseline eval

mandatoryprescriber sig

Coverage Criteria for Austedo (deutetrabenazine)

Initial and continuation criteria — Tardive Dyskinesia

Policy Summary

PayerUnitedHealthcare

PolicyAustedo (deutetrabenazine) prior authorization for movement disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Tardive Dyskinesia initial and continuation criteria: 1) Diagnosis of moderate to severe Tardive Dyskinesia; 2) Age 18 years or older; 3) Provider has submitted documented baseline evaluations using the Abnormal Involuntary Movement Scale (AIMS) or the Extrapyramidal Symptom Rating Scale (ESRS); 4) Documentation whether the beneficiary had a previous trial of an alternative method to manage the condition; 5) Beneficiary is not receiving dual therapy with other VMAT2 inhibitors; 6) Beneficiary is not concurrently using a monoamine oxidase inhibitor (MAOI) or reserpine; 7) For continuation requests, documentation is attached showing the beneficiary is receiving treatment and/or is stable and has had improvement in symptoms from baseline.all true

For continuation, attach documentation showing improvement from baseline and indicate treatment stability.

Initial and continuation criteria — Huntington's Disease

Covered when ALL of the following are met for Huntington's Disease chorea:

Huntington's Disease chorea initial and continuation criteria: 1) Diagnosis of Huntington's Disease with signs and symptoms of chorea; 2) Age 18 years or older; 3) Beneficiary is not receiving dual therapy with other VMAT2 inhibitors; 4) Beneficiary is not concurrently using a monoamine oxidase inhibitor (MAOI) or reserpine; 5) Documentation of any history of depression or suicidal ideation is provided and considered; 6) For continuation requests, documentation is attached showing the beneficiary is receiving treatment and/or is stable and has had improvement in symptoms from baseline; 7) Prescriber signature and date are provided on the form.all true

Assess and document history of depression or suicidal ideation as indicated on the form; for continuation, attach documentation showing improvement from baseline and indicate treatment stability.

Concurrent use of another VMAT2 inhibitor, or concurrent use of a MAOI (monoamine oxidase inhibitor) or reserpine, is captured on the prior authorization form and will preclude approval unless a clear justification is provided. The form explicitly asks whether the beneficiary is receiving dual VMAT2 therapy (Tardive Dyskinesia question 5; Huntington's Disease question 3) and whether the beneficiary is concurrently using a MAOI or reserpine (Tardive Dyskinesia question 6; Huntington's Disease question 4).

Requests for Austedo must include required baseline assessments and documentation of benefit for continuation. For Tardive Dyskinesia the form requires submission of a documented baseline evaluation using either the Abnormal Involuntary Movement Scale (AIMS) or the Extrapyramidal Symptom Rating Scale (ESRS) and asks whether a prior alternative treatment trial occurred. For continuation requests, attach documentation showing improvement from baseline and indicate whether the beneficiary is stable. Use without these baseline assessments or without documentation of improvement on continuation may be considered not medically necessary. The Huntington's Disease section likewise requires documentation of chorea symptoms and documents history of depression or suicidal ideation as indicated, with continuation requests requiring evidence of symptomatic improvement from baseline.

Drug Coding and Duration Selections

Drug/NDC entriesNDC

NDC	Not specified on form; drug name/strength/quantity to be entered

Length of Therapy selection — allowed day ranges for initial and continuation requests

Initial request allowed lengthsSelect one: up to 30 days, 60 days, 90 days, 120 days, or 180 days

Continuation request allowed lengthsSelect one: up to 30 days, 60 days, 90 days, 120 days, 180 days, or 365 days

Form fields required for length selectionLength of Therapy (in days) must be indicated on the NC Pharmacy Prior Approval form

Provider Actions, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Form Completion

Prior authorization is required using the NC Pharmacy Prior Approval Request form (for Movement Disorders: Austedo). The prescriber must complete and sign the form; unsigned requests will be denied.

Use the NC Pharmacy Prior Approval Request for Movement Disorders: Austedo
Prescriber signature is mandatory
Include drug name, strength, quantity per 30 days, and requested length of therapy

Denial Risk

Triggers for Denial

Requests without a documented baseline AIMS or ESRS evaluation, missing prescriber signature, or lacking documentation of prior alternative treatment for tardive dyskinesia are subject to denial. For continuation requests, absence of documentation showing improvement from baseline may result in denial.

Missing baseline Abnormal Involuntary Movement Scale (AIMS) or Extrapyramidal Symptom Rating Scale (ESRS) evaluation — denial trigger
Absent prescriber signature on the NC Pharmacy Prior Approval Request form — denial trigger
No documentation of improvement from baseline for continuation requests — denial trigger

Documentation Required

Previous Treatment Trial (Tardive Dyskinesia)

For tardive dyskinesia, the request must document a prior trial of an alternative method to manage the condition (per question 4 on the movement disorders form). If no prior trial is documented, the request may be denied.

Document prior alternative treatment trial for tardive dyskinesia (answer to: Has the beneficiary had a previous trial of an alternative method to manage the condition?)
Indicate whether beneficiary is age ≥18 and has a diagnosis of moderate to severe tardive dyskinesia

Key Definitions

Baseline evaluation — AIMS or ESRS required

Required baseline assessment optionsProvider must submit documented baseline evaluations using either the Abnormal Involuntary Movement Scale (AIMS) or the Extrapyramidal Symptom Rating Scale (ESRS)

Indication tied to baseline requirementBaseline AIMS or ESRS is required for requests for Tardive Dyskinesia (moderate to severe)

Documentation use for continuationFor continuation requests, attach documentation showing improvement from baseline (comparison to submitted AIMS/ESRS)

Background

Austedo (deutetrabenazine) is used to treat hyperkinetic movement disorders addressed on the prior authorization form: moderate to severe Tardive Dyskinesia and chorea associated with Huntington's Disease. The form collects key clinical information to support medical necessity, including age (must be ≥18 years), baseline movement assessments (AIMS or ESRS) for Tardive Dyskinesia, documentation of prior treatment attempts, and screening for concurrent MAOI/reserpine or dual VMAT2 therapy. For Huntington's Disease the form also requests documentation of any history of depression or suicidal ideation to inform risk assessment. Continuation approvals require documentation demonstrating improvement from baseline and treatment stability.