CurrentUnitedHealthcarePolicy CSIND0037.09

Repository Corticotropin Injections (for Indiana Only)

Defines UnitedHealthcare Medical Benefit Drug Policy coverage guidance for repository corticotropin injections for members in Indiana; refers providers to InterQual specialty Rx non-oncology repository corticotropins criteria for medical necessity.

Policy Summary

PayerUnitedHealthcare

PolicyRepository Corticotropin Injections (for Indiana Only)

Policy CodePolicy CSIND0037.09

Change TypeRoutine reviewno content changes

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization per plan rules and meet the InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins criteria for coverage.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

1applicable state

2HCPCS codes listed

1external clinical criteria referenced

0related policies listed

Coverage Criteria

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Coverage contingent on InterQual criteria

Covered when the InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins criteria are met.

InterQual-based approval: Acthar Gel and Purified Cortrophin Gel are proven and medically necessary for the treatment of certain conditions outlined within the InterQual criteria.refer to current InterQual release

Providers must follow the current InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins for specific indication, clinical requirements, and step therapy; prior authorization requirements are determined per plan rules referencing InterQual.

Listing of a code in this policy does not imply the service is covered. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws, which may mandate coverage for a specific service. The inclusion of a code in this policy does not guarantee reimbursement or claim payment; other policies and guidelines may apply.

Provider Actions & Authorization

Prior Authorization

Prior authorization guided by InterQual

Coverage and medical necessity determinations for Acthar Gel and Purified Cortrophin Gel are governed by the InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins criteria; obtain any required prior authorization per plan rules that reference these InterQual criteria.

Step Therapy

Step therapy per InterQual

Any step therapy requirements for repository corticotropin injections are those specified within the InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins criteria and must be followed when referenced by the plan.

Documentation Required

Follow InterQual and governing benefit documents

For medical necessity clinical coverage criteria, providers must refer to the current release of the InterQual guideline CP: Specialty Rx Non-Oncology, Repository Corticotropins; UnitedHealthcare policy assists interpretation but federal, state, or contractual requirements govern in case of conflict.

Denial Risk

Coding inclusion disclaimer

Listing of a code in this policy is for reference only and does not mean the service described by the code is covered or not covered; benefit coverage and reimbursement depend on federal, state, or contractual requirements and applicable laws.

Initial Therapy Criteria

Initial therapy requirements

Initial coverage is determined by meeting the InterQual repository corticotropins criteria.

Initial approval: Patient meets InterQual criteria for a covered indication for repository corticotropin injection (Acthar Gel or Purified Cortrophin Gel).see InterQual

Policy defers to the current InterQual release for specific clinical requirements and any step therapy or prior authorization conditions.

Definitions

Repository corticotropin injections — definitions and guidance

DefinitionRepository corticotropin injections — branded products include Acthar Gel and Purified Cortrophin Gel (repository corticotropin injection USP).

Clinical roleProven and medically necessary for treatment of certain conditions when InterQual criteria are met.

Guiding external criteriaMedical necessity decisions reference the InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins (current release).

Provider actionProviders should consult the current InterQual guideline for specific indication and clinical requirements before seeking authorization.

Policy scopeThis definition is applicable to UnitedHealthcare medical benefit drug policy determinations for repository corticotropin injections.

Background

Acthar Gel (repository corticotropin injection) and Purified Cortrophin Gel (repository corticotropin injection USP) are repository corticotropin injections used to treat certain inflammatory and autoimmune conditions. This policy defers detailed medical necessity determinations to the InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins guideline, which governs specific indications, clinical requirements, and any step-therapy or prior authorization expectations.

Site of Care

Billing Rule

Verify site-of-care and benefits with plan terms

Site-of-care and benefit determinations for administration (e.g., infusion center) depend on the member's federal, state, or contractual benefit plan terms; check the applicable benefit plan before billing or scheduling services.