CurrentUnitedHealthcarePolicy N/A

Gattex (teduglutide) prior authorization

Defines prior authorization and reauthorization requirements for Gattex (teduglutide) for members receiving care under UnitedHealthcare. Applies to providers requesting coverage for Gattex for eligible members.

Policy Summary

PayerUnitedHealthcare

PolicyGattex (teduglutide) prior authorization

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateNov 16, 2025

Next Review DateSep 25, 2025

Key ActionSubmit documentation of Short Bowel Syndrome diagnosis and dependence on parenteral support for initial prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

≥1 yrminimum age

SBSindication

9/2025latest review

Coverage Criteria for Gattex (teduglutide)

Initial Therapy — Gattex will be approved based upon both of the following criteria:

Policy Summary

PayerUnitedHealthcare

PolicyGattex (teduglutide) prior authorization

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateNov 16, 2025

Next Review DateSep 25, 2025

Key ActionSubmit documentation of Short Bowel Syndrome diagnosis and dependence on parenteral support for initial prior authorization.

SourceLink

On This Page

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In addition to the coverage criteria listed, UnitedHealthcare may apply program-specific rules that affect approval. This includes using prior claim or medication history, diagnosis codes (ICD-10), and automated claim logic to approve initial requests or reauthorizations without additional documentation. Providers should be aware that state mandates, federal requirements, and individual member benefit plan terms may further restrict coverage or impose documentation requirements beyond those in this policy, and supply limits may be in place.

Initial Authorization Criteria

Initial Authorization

Initial prior authorization requires documentation of the diagnosis and parenteral support dependence; approval will be issued for 12 months.

Diagnosis of Short Bowel Syndrome (SBS)
Parenteral support: Member is dependent on parenteral support
Authorization will be issued for 12 months

Operational note: Authorization duration: 12 months

Reauthorization / Continuation Criteria

Reauthorization

Reauthorization requires documentation of a positive clinical response to Gattex; approval will be issued for 12 months.

Reauthorization: Documentation of positive clinical response to Gattex therapy

Authorization will be issued for 12 months

Compliance notes: State mandates, federal requirements, and the member-specific benefit plan may affect reauthorization determinations

Provider Actions and Authorization Workflow

Prior Authorization

Initial Authorization — Required documentation and approval duration

Initial authorization requires documentation of the member's diagnosis and dependency on parenteral support. Specifically, approval is granted when there is: (1) a diagnosis of Short Bowel Syndrome (SBS) AND (2) evidence the member is dependent on parenteral support. Authorizations issued for initial requests will be granted for 12 months.

Diagnosis: Short Bowel Syndrome (SBS).
Dependency: Documented need for parenteral support (e.g., TPN).
Approval duration: 12 months.

Prior Authorization

Reauthorization — Documentation and approval duration

Reauthorization requires documentation demonstrating a positive clinical response to therapy. Provide clinical notes, weight/nutritional status improvements, reductions in parenteral support volume/frequency, or other objective measures showing benefit from therapy. Authorizations for reauthorization will be issued for 12 months.

Documentation of positive clinical response (clinical notes, lab values, weight trends).
Objective evidence of reduced dependence on parenteral support when applicable.
Approval duration: 12 months.
State and federal mandates and the member-specific benefit plan may affect coverage.

Note

Automated approval/re-approval may apply

UnitedHealthcare may use automated approval or re-approval processes that rely on prior claims/medication history, diagnosis codes (ICD-10), and claim logic. When applicable, prior authorization may be approved without additional documentation if the automated review confirms eligibility.

Automated approvals based on prior claims/medication history, diagnosis codes (ICD-10), and claim logic.
Use of automated approval varies by program and therapeutic class.

Documentation Required

Required documentation — initial and reauthorization

For both initial authorizations and reauthorizations, include complete clinical documentation to support medical necessity. This should include diagnosis, treatment history, current medication list, objective measures of treatment response, and documentation of parenteral support dependence or changes. Include any additional documentation required to satisfy state or federal regulatory requirements and the member's benefit plan.

Include: diagnosis, treatment history, current medications, clinical notes, lab/test results, objective response measures (e.g., weight, nutritional markers).
Document parenteral support dependence (type, volume, frequency) and any reductions over time for reauthorization.
Attach prior authorization forms and any program-specific paperwork as required.

Denial Risk

Denial triggers and supply limits

Denials may occur if required documentation is incomplete, if clinical criteria are not met (e.g., no SBS diagnosis or no evidence of parenteral support dependence), or if supply limits are exceeded. Supply limits or other utilization controls may be applied per program rules.

Denial triggers: lack of SBS diagnosis, no documented dependence on parenteral support, insufficient evidence of clinical benefit on reauthorization.
Supply limits may apply and can result in partial approvals or denials.

Key Definitions

Short Bowel Syndrome (SBS) — definition and relation to parenteral support

DefinitionShort Bowel Syndrome (SBS): clinical condition for which Gattex is indicated; members must be dependent on parenteral support.

Age indicationApplies to adults and pediatric patients 1 year of age and older.

Treatment classGattex (teduglutide) is a glucagon-like peptide-2 (GLP-2) analog.

Coverage requirementMembers must meet the policy’s coverage criteria to be eligible for Gattex therapy.

Gattex (teduglutide) — quantity limits / supply-limit note (quick reference)

Quantity limit noteSupply limits may be in place for Gattex (teduglutide).

Automated approvalsUnitedHealthcare may use previous claim/medication history, diagnosis codes, and claim logic which can affect supply handling.

Program variabilityUse of automated approval and re-approval processes varies by program and/or therapeutic class.

OpenPayer