CurrentUnitedHealthcarePolicy 2025 P 1450-2

Demser (metyrosine) prior authorization

Prior authorization and reauthorization criteria for Demser (metyrosine) for treatment of pheochromocytoma for UnitedHealthcare members; affects prescribers and pharmacy benefits reviewers.

Policy Summary

PayerUnitedHealthcare

PolicyDemser (metyrosine) prior authorization

Policy CodePolicy 2025 P 1450-2

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting a diagnosis of pheochromocytoma for initial approval; provide documentation of positive clinical response for reauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

7/2024, 7/2025P&T dates

pheochromocytomaapproved diagnosis

essential HTNnon-recommended use

Coverage Criteria for Demser (metyrosine)

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Continuation / Reauthorization Criteria

Continuation Therapy

Reauthorization/continuation criteria

Continuation: Documentation of positive clinical response; authorization issued for 12 months

Continuation approvals are valid for 12 months and may be influenced by state mandates and member benefit plans.

Provider Actions & Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Demser (metyrosine). Initial approval is contingent on documentation showing a diagnosis of pheochromocytoma.

Required for initial and reauthorization: submit prior authorization request per UnitedHealthcare processes.

Note

Automated approval/process note

The program may allow automated approval or reauthorization based on prior claims/medication history, submitted diagnosis codes (ICD-10), and claim logic. Availability of automated approvals varies by program and therapeutic class.

Automated approvals may use past claim history and diagnosis codes to approve without additional clinical documentation.

Documentation Required

Required documentation for reauthorization

For reauthorization, submit documentation demonstrating a positive clinical response to therapy. Authorization, when approved, will be issued for 12 months.

Reauthorization must include clinical notes or assessments documenting improvement on therapy.
Authorization duration: 12 months per approval.

Denial Risk

Initial authorization denial trigger

Absence of a documented diagnosis of pheochromocytoma on the initial prior authorization request will result in denial of the initial authorization.

Initial approval requires documented diagnosis of pheochromocytoma (see initial authorization criteria).

Denial Risk

Reauthorization denial trigger

Lack of documentation showing a positive clinical response during the reauthorization review period may result in denial of continued coverage.

If clinical improvement is not documented, reauthorization may be denied.
Ensure objective measures or clinician assessment notes are included with reauthorization requests.

Program action	Criteria used	Coverage status
Automated initial approval or re-approval	Previous claim/medication history and diagnosis codes (ICD-10); program-specific claim logic	Approvals may be granted based on these data as allowed by program

Definitions

Demser (metyrosine) — drug definition and indication summary

Generic and brand namemetyrosine (Demser)

Primary indication (highlight)Preoperative preparation and treatment of pheochromocytoma (including when surgery is contraindicated and chronic treatment of malignant pheochromocytoma)

Drug classTyrosine hydroxylase inhibitor

Not recommended useNot recommended for control of essential hypertension

Typical roleUsed to reduce catecholamine synthesis in patients with pheochromocytoma to assist perioperative management or for chronic control in malignant cases