CurrentUnitedHealthcarePolicy 2025 P 1477-1

Pa Notification Romvimza

UnitedHealthcare prior authorization/notification policy for Romvimza (vimseltinib) governing coverage criteria for initial and continued use for tenosynovial giant cell tumor (TGCT), including special handling for members under 19 and reference to NCCN recognition and state mandates.

Policy Summary

PayerUnitedHealthcare

PolicyPa Notification Romvimza

Policy CodePolicy 2025 P 1477-1

Change TypeNew prior authorization program (P&T 4/2025)

Effective DateJul 1, 2025

Next Review Date

Key ActionRomvimza is managed under UnitedHealthcare's prior authorization/notification program; members under age 19 auto-process without coverage review. Authorization for approved requests will be issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

New prior authorization program for Romvimza (vimseltinib) established with P&T approval 4/2025 and effective date 7/1/2025.

12 monthsAuthorization duration

4/2025P&T Approval

Under 19Pediatric auto-processing

Covered w/ criteriaCoverage stance

Coverage Summary

UnitedHealthcare prior authorization/notification policy for Romvimza (vimseltinib) governing coverage criteria for initial and continued use for tenosynovial giant cell tumor (TGCT). Coverage stance: covered_with_criteria. Policy number: 2025 P 1477-1. Effective date: 2025-07-01. Last review: 2025-04-01.

Initial Therapy Criteria (Adults and applicable members)

Initial Authorization (Adults and applicable members)

Romvimza will be approved based on both of the following criteria:

ALL of the following

Diagnosis of tenosynovial giant cell tumor (TGCT)
Surgical resection will potentially cause worsening functional limitation or severe morbidity

Patients less than 19 years of age

Romvimza will be approved based on the following criterion:

ALL of the following

Patient is less than 19 years of age

Continuation / Reauthorization Criteria

Reauthorization / Continued Therapy

Romvimza will be approved for reauthorization when the following is met:

ALL of the following

Patient does not show evidence of progressive disease while on Romvimza therapy

Guideline / Recognition

NCCN Recognition

Supportive recognition:

ANY of the following

The drug is recognized for the cancer indication by the NCCN Drugs and Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B

Evidence: Romvimza [package insert], Deciphera Pharmaceuticals, LLC; February 2025. The policy references the product label (Feb 2025) and notes NCCN recognition for the cancer indication per the NCCN Drugs and Biologics Compendium.

Provider Actions & Requirements

Prior Authorization

Prior Authorization / Notification Required

Romvimza is managed under UnitedHealthcare's prior authorization/notification program; members under age 19 auto-process without coverage review. Authorization for approved requests will be issued for 12 months.

Authorization duration = 12 months

Documentation Required

Clinical documentation for initial approval

Provider must document diagnosis of TGCT and that surgical resection would potentially cause worsening functional limitation or severe morbidity.

Documentation Required

Documentation for reauthorization

Provider must document lack of evidence of progressive disease while on Romvimza to support reauthorization.

Billing Rule

Supply limits and automated approvals

Supply limits may be in place and UnitedHealthcare may approve initial and reauthorization based solely on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic.

Automated approvals may use prior claim/medication history, ICD-10 diagnosis codes, and/or claim logic

Documentation Required

State and benefit plan mandates

Providers should confirm state mandates and member-specific benefit plans as mandates may supersede these criteria.

Background & Definitions

Romvimza is a kinase inhibitor indicated for adult patients with symptomatic tenosynovial giant cell tumor (TGCT) where surgical resection would potentially worsen functional limitation or cause severe morbidity. This indication is taken from the product label (Feb 2025); the drug is also recognized by the NCCN Drugs and Biologics Compendium for this cancer indication.

TGCT: Tenosynovial giant cell tumor.

Policy Summary

PayerUnitedHealthcare

PolicyPa Notification Romvimza

Policy CodePolicy 2025 P 1477-1

Change TypeNew prior authorization program (P&T 4/2025)

Effective DateJul 1, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

Pa Notification Romvimza

Coverage Summary

Initial Therapy Criteria (Adults and applicable members)

Continuation / Reauthorization Criteria

Guideline / Recognition

Provider Actions & Requirements

Applicable Codes

Background & Definitions

Clinical Evidence

Revision History