CurrentUnitedHealthcarePolicy N/A

Gattex (teduglutide) prior authorization for short bowel syndrome

This document is a prior authorization form for Gattex (teduglutide) intended for prescribers requesting initial or reauthorization of treatment for beneficiaries with short bowel syndrome (SBS) who are receiving parenteral nutrition. It governs documentation and eligibility questions required by the payer for coverage decisions.

Policy Summary

PayerUnitedHealthcare

PolicyGattex (teduglutide) prior authorization for short bowel syndrome

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form confirming age, SBS diagnosis, duration and frequency of parenteral nutrition, and obtain prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age ≥ 1minimum beneficiary age queried

≥ 12 monthsPN duration queried

≥ 3x/weekPN frequency queried

30-365 daystherapy length options

prescriber signaturesignature required

Coverage Criteria for Gattex (teduglutide)

inv-01: Initial Therapy — Covered when ALL of the following are met for initial authorization

Covered when ALL of the following are met for initial authorization

Initial Authorization for Gattex: Beneficiary is age 1 or older; beneficiary has a diagnosis of short bowel syndrome (SBS); beneficiary has been dependent on parenteral nutrition for at least 12 months; beneficiary is receiving parenteral nutrition at least 3 times per week.

Extracted from form checklist

inv-02: Continuation Therapy / Reauthorization — Covered for reauthorization when the following is confirmed

Covered for reauthorization when the following is confirmed

Reauthorization for Gattex: Beneficiary is continuing to receive parenteral nutrition while taking Gattex; prescriber signature and date are provided on the form.

Extracted from reauthorization checklist and signature requirement

Policy Summary

PayerUnitedHealthcare

PolicyGattex (teduglutide) prior authorization for short bowel syndrome

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form confirming age, SBS diagnosis, duration and frequency of parenteral nutrition, and obtain prescriber signature.

SourceLink

On This Page

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The form’s eligibility checklist establishes that requests for Gattex (teduglutide) are intended for beneficiaries with short bowel syndrome (SBS) who meet specific clinical thresholds. For initial authorization the prescriber must confirm the beneficiary is age ≥ 1 year, has a diagnosis of SBS, has been dependent on parenteral nutrition for ≥ 12 months, and is receiving parenteral nutrition at least 3 times per week.

The form indicates that requests failing to provide affirmative answers to the required eligibility questions — including age (≥ 1 year), documented diagnosis of SBS, duration of parenteral nutrition dependence ( ≥ 12 months ), and frequency of parenteral nutrition ( ≥ 3 times/week for initial requests) — or lacking the prescriber’s signed attestation may be considered administratively incomplete or not medically necessary.

Initial Authorization Requirements

Reauthorization / Continuation Requirements

inv-16: Reauthorization — Reauthorization requirement

Reauthorization requirement

Reauthorization: Confirm beneficiary is continuing to receive parenteral nutrition while taking Gattex; prescriber signature and date on form.

From reauthorization section

What the Prescriber Must Provide

Prior Authorization

Prior Authorization Required

Prior authorization checklist — Initial and reauthorization requests require completion of the form questions confirming age, SBS diagnosis, dependence on parenteral nutrition, frequency of parenteral nutrition, and for reauthorization whether the patient continues to receive parenteral nutrition while on therapy. The prescriber must sign and date the form. Incomplete or unsigned forms may delay processing.

Complete beneficiary information (last name, first name, beneficiary ID, DOB, gender).
Complete prescriber information (prescribing provider NPI, requester contact name and phone).
Complete drug information (drug name, strength, quantity per 30 days, length of therapy).
Answer all checklist questions for initial OR reauthorization requests as applicable.
Prescriber signature and date are mandatory.

Step Therapy

No step therapy requirements are specified on the form. If a step-therapy requirement applies under the member’s benefit, the prescriber may be contacted for additional information or an alternative therapy may be requested.

Documentation Required

Required Form Fields

Required form fields — The following fields must be completed to process the request: beneficiary last name, first name, beneficiary ID, date of birth, gender; prescribing provider NPI, requester contact name and phone; drug name, strength, quantity per 30 days, and selected length of therapy. For initial requests, complete the age and SBS/parenteral nutrition questions; for reauthorization, answer the continuation-on-parenteral-nutrition question.

Beneficiary: last name, first name, member ID, DOB, gender.
Prescriber: NPI, requester contact name and phone number.
Drug: name, strength, quantity per 30 days, length of therapy selection.
Checklist responses for initial or reauthorization requests as applicable.
Prescriber signature and date.

Denial Risk

Documentation and Denial Risk

Documentation and eligibility omissions — Missing, negative, or inconsistent answers to the eligibility questions (for example, age under 1, no SBS diagnosis, less than 12 months dependent on parenteral nutrition, or not receiving parenteral nutrition ≥3 times/week for initial requests; or not continuing parenteral nutrition for reauthorization) or an unsigned form may result in denial or a request for additional information. Provide supporting clinical records when applicable (e.g., diagnosis documentation, parenteral nutrition history).

Missing prescriber signature will delay or deny the request.
Negative or missing answers to SBS/parenteral nutrition eligibility questions may lead to denial.
Attach clinical documentation of SBS diagnosis and parenteral nutrition dependency/history when available.

Key Eligibility Metrics and Codes

inv-05: Minimum age — 1 year

Minimum ageBeneficiary must be age 1 year or older for initial authorization.

ContextQuestion 1 on the initial authorization checklist asks: 'Is the beneficiary age 1 or older?'

ImplicationRequests for beneficiaries under 1 year are not eligible under the initial authorization criteria on the form.

inv-06: Parenteral nutrition duration — ≥ 12 months

Parenteral nutrition durationBeneficiary must have been dependent on parenteral nutrition for at least 12 months for initial authorization.

Source questionForm question: 'Has the beneficiary been dependent on parenteral nutrition for at least 12 months?'

Role in decisionAffirmative response is required on the initial authorization checklist to meet coverage criteria.

inv-07: Parenteral nutrition frequency — ≥ 3 times per week

Parenteral nutrition frequencyBeneficiary must be receiving parenteral nutrition at least 3 times per week for initial authorization.

Form itemQuestion 4: 'Is the beneficiary receiving parenteral nutrition at least 3 times per week?'

Authorization impactAn affirmative answer is required on the initial checklist to satisfy the frequency criterion.

Step Therapy Requirements

Step	Requirement	Notes
No step therapy steps are documented on the form.	The prior authorization form does not list any prerequisite medication trials or stepwise treatment requirements for Gattex (teduglutide).	Providers are not required by the form to document failure or intolerance of other therapies prior to approval.

Quantity and Supply Limits

inv-18: Gattex (teduglutide) — Quantity per 30 days as specified on form

Quantity per 30 daysQuantity per 30 days to be completed on the form (as specified in 'Drug Information: Quantity Per 30 Days').

Where documentedField 10 on the Drug Information section captures 'Quantity Per 30 Days'.

Applies toGattex (teduglutide) requests — prescriber must specify the requested quantity on the form.

Site of Care and Administration

Note

No site-of-care restrictions on form

The form does not restrict site of care; no infusion center or other site-of-care limitations are specified on the prior authorization form.

Background

This prior authorization form is specific to requests for Gattex (teduglutide) in patients with short bowel syndrome (SBS) who require parenteral nutrition. The form captures the core eligibility elements used to determine coverage: beneficiary age, confirmed SBS diagnosis, duration and frequency of parenteral nutrition for initial requests, and confirmation of ongoing parenteral nutrition with a prescriber signature for reauthorization.

Definitions

inv-13: SBS — Short bowel syndrome queried as part of eligibility

DefinitionShort bowel syndrome (SBS) — diagnosis is queried as part of the initial authorization eligibility questions.

Form locationQuestion 2 on the initial authorization checklist asks: 'Does the beneficiary have a diagnosis of short bowel syndrome (SBS)?'

Coverage roleAn affirmative SBS diagnosis is required to meet initial authorization criteria for Gattex per the form.

inv-14: Parenteral nutrition dependence — Dependence for at least 12 months queried for initial authorization

PN dependence duration for initial requestsInitial authorization requires documented dependence on parenteral nutrition for at least 12 months.

Reauthorization requirementFor reauthorization the form queries that the beneficiary is continuing to receive parenteral nutrition while taking Gattex (Question 5).

DocumentationProviders must complete the checklist items and sign/date the form for both initial and reauthorization requests.