CurrentUnitedHealthcarePolicy CSOH2025D0214.D

Nplate (Romiplostim) (Ohio Only) Medical Benefit Drug Policy

Defines UnitedHealthcare Community Plan coverage and medical necessity determination for Nplate (romiplostim) for members in Ohio, directing clinicians to InterQual criteria for specific clinical indications.

Policy Summary

PayerUnitedHealthcare

PolicyNplate (Romiplostim) (Ohio Only) Medical Benefit Drug Policy

Policy CodePolicy CSOH2025D0214.D

Change TypeCoverage rationale revised — refer to InterQual

Effective DateNov 1, 2025

Next Review Date

Key ActionFollow the current InterQual Romiplostim guideline for coverage and medical necessity determinations and bill using HCPCS code J2802.

SourceLink

POLICY UPDATE CHANGES

Removed language pertaining to specific treatment indications; refer to the InterQual criteria listed in the policy for applicable coverage guidelines.

Archived previous policy version CSOH2025D0214.C.

Ohio-onlyapplicability

J2802HCPCS

InterQualcriteria source

Coverage and Medical Necessity Criteria

Coverage Rationale (delegated to InterQual)

Policy Summary

PayerUnitedHealthcare

PolicyNplate (Romiplostim) (Ohio Only) Medical Benefit Drug Policy

Policy CodePolicy CSOH2025D0214.D

Change TypeCoverage rationale revised — refer to InterQual

Effective DateNov 1, 2025

Next Review Date

Key ActionFollow the current InterQual Romiplostim guideline for coverage and medical necessity determinations and bill using HCPCS code J2802.

SourceLink

On This Page

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Clinical coverage determinations for Nplate (romiplostim) are delegated to the current InterQual Specialty Rx Non-Oncology Romiplostim guideline. Use of Nplate for indications not supported by the InterQual Romiplostim criteria may be considered not medically necessary and will be evaluated according to the InterQual guidance referenced in this policy.

As noted in the policy history, language describing specific treatment indications was removed; providers must refer to the InterQual criteria listed in the policy for applicable coverage guidelines.

Provider Actions, Authorization & Documentation

Prior Authorization

Provider Actions, Authorization & Documentation

Prior authorization and medical necessity determinations follow the current InterQual guideline for Romiplostim (Nplate®). Providers must obtain prior authorization when required by the member's benefit plan and submit documentation that references InterQual criteria and any applicable federal, state (Ohio Administrative Code 5160-1-01), or contractual requirements. Requests that do not meet InterQual criteria, request unproven indications, or exceed quantity/coverage limits may be denied.

Coverage and medical necessity determinations follow current InterQual guidelines for Nplate® (Romiplostim).
No step therapy specifics are listed in this policy; clinical criteria and any step therapy requirements are delegated to and determined by InterQual.
Providers must reference federal, state (OAC 5160-1-01), or contractual requirements when submitting documentation — those requirements govern in the event of a conflict with this policy.
Requests that do not meet InterQual criteria, are for unproven indications, or exceed allowable quantity limits may be denied; include all relevant clinical documentation with prior authorization requests.

Documentation Required

Required Documentation Guidance

Providers should use InterQual as the primary source for clinical criteria and prior authorization determination. When submitting documentation include clinical notes, prior treatments, lab results, dosing history, and any other information required by InterQual or by federal/state/contractual rules.

Submit full clinical documentation (diagnosis, prior therapies, labs, dosing history) with PA requests.
Follow any additional submission requirements from federal, state (OAC), or contractual sources.
InterQual criteria drive clinical coverage decisions; absence of step therapy details in this policy means any step therapy rules are defined within InterQual or benefit plan documents.

Denial Risk

Denial Triggers

Denial risk exists when requests do not meet InterQual criteria, are for indications considered unproven, or exceed quantity/coverage limits. Providers may receive a request for additional information; failure to supply required documentation can result in denial.

Denials likely if InterQual criteria are not met.
Denials may occur for unproven indications or requests exceeding quantity/coverage limits.
Provide requested additional information promptly to avoid denial.

Site-of-Care Considerations

Note

Infusion‑center site‑of‑care considerations

Site-of-care requirements (including infusion center use) should follow the member's benefit plan, applicable federal/state (OAC) requirements, and InterQual guidance where applicable.

Verify the member's benefit plan for site-of-care coverage rules.
If federal, state (OAC), or contractual requirements conflict with this policy, those requirements govern.
Use InterQual site-of-care guidance when applicable to clinical decision-making.

Definitions

InterQual — definition / reference to InterQual guideline

DefinitionInterQual: the InterQual specialty drug clinical guideline used to define medical necessity for Nplate (romiplostim).

ScopeInterQual guideline (CP: Specialty Rx Non-Oncology, Romiplostim [Nplate]) is the authoritative source for clinical coverage criteria for Nplate in this policy.

AccessRefer to the current release of the InterQual guideline via the UnitedHealthcare provider InterQual Clinical Criteria link for indication-specific requirements.

Role in policyThis policy delegates medical necessity determinations for Nplate to the InterQual guideline; requests are evaluated against InterQual criteria rather than enumerated indications in the policy.

Implementation noteUse the InterQual criteria referenced by UnitedHealthcare when submitting authorization requests for romiplostim (Nplate).

OpenPayer

Nplate (Romiplostim) (Ohio Only) Medical Benefit Drug Policy

Coverage and Medical Necessity Criteria

Initial Therapy

Provider Actions, Authorization & Documentation

Coding and Billing

Site-of-Care Considerations

Background

Definitions