DraftUnitedHealthcarePolicy N/A

Tardive Dyskinesia pharmacotherapy prior authorization form — Coverage Criteria

Authorization form and requirements for pharmacologic treatment of moderate to severe tardive dyskinesia for UnitedHealthcare beneficiaries, including prescriber, beneficiary, drug, and clinical documentation fields.

Policy Summary

PayerUnitedHealthcare

PolicyTardive Dyskinesia pharmacotherapy prior authorization form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including diagnosis confirmation, age verification (18+), baseline AIMS or ESRS assessment, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6required clinical questions on form

up to 365 Daysmax continuation duration

age >=18age requirement queried

AIMS or ESRSbaseline assessment tools

Coverage Criteria

Initial/Continuation Authorization Criteria

Authorization is requested when ALL of the following are provided/confirmed:

Administrative and prescriber information: Beneficiary identifying information (name, beneficiary ID, date of birth, gender) and prescriber information including prescribing provider NPI and requester contact (name, phone) are provided; prescriber signature and date certifying accuracy are required.

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Diagnosis and age: Provider confirms the beneficiary has a diagnosis of moderate to severe Tardive Dyskinesia and is age 18 years or older.

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Baseline assessment: Submission includes documented baseline evaluation using either the Abnormal Involuntary Movement Scale (AIMS) or the Extrapyramidal Symptom Rating Scale (ESRS).

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Policy Summary

PayerUnitedHealthcare

PolicyTardive Dyskinesia pharmacotherapy prior authorization form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including diagnosis confirmation, age verification (18+), baseline AIMS or ESRS assessment, and prescriber signature.

SourceLink

On This Page

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Prior therapy and concomitant medications: Provider indicates whether the beneficiary had a previous trial of an alternative management method, whether the beneficiary is receiving dual VMAT2 inhibitor therapy, and whether the beneficiary is concurrently using a MAOI or reserpine.

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Drug request details: Requested drug name, strength, quantity per 30 days, and requested length of therapy (initial or continuation with allowed duration options) are specified.

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The form does not enumerate specific non‑covered (NMN) conditions. However, authorization depends on completion of required items on the form; omission of those items may result in denial. In particular, the request must include beneficiary and prescriber administrative data and the prescriber’s signature, a confirmed diagnosis of moderate to severe Tardive Dyskinesia, age verification (the form asks whether the beneficiary is 18 or older), and any required clinical assessments. Absence of the documented baseline assessment using the AIMS or ESRS, or failure to provide the prescriber signature or continuation documentation of improvement, are examples of missing elements that the form identifies as grounds that may trigger denial.

Initial Therapy

Initial therapy

Initial request options and required documentation

Initial therapy documentation: For initial requests, specify the requested length of therapy (selectable options: up to 30, 60, 90, 120, or 180 days) and include a baseline assessment documented with AIMS or ESRS attached to the request.Initial: up to 30, 60, 90, 120, 180 days

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Continuation Therapy

Continuation requirements

For continuation requests the form requires documentation of symptomatic improvement from baseline and allows durations up to 365 days.

Continuation documentation: Attach documentation demonstrating the beneficiary has had improvement in symptoms from baseline; prescriber signature and date are required to certify the information.Continuation: up to 30, 60, 90, 120, 180, 365 days

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Provider Actions & Prior Authorization Steps

Prior Authorization

Prior Authorization Required

Prior authorization is required for this medication. Complete the prior authorization form in full, including confirmation of diagnosis (moderate to severe Tardive Dyskinesia), beneficiary age verification (18 or older), therapy type (initial vs continuation), requested length of therapy, and prescriber attestation. Incomplete forms may delay processing.

Diagnosis confirmation required: moderate to severe Tardive Dyskinesia
Age verification: beneficiary must be >= 18 years (Yes/No)
Specify initial vs continuation request and requested length of therapy

Documentation Required

Administrative Documentation — required form fields

Ensure beneficiary, prescriber, and drug fields are completed: beneficiary name, ID, DOB, gender; prescriber NPI, requester contact name and phone; drug name, strength, quantity per 30 days, and length of therapy (select appropriate interval for initial or continuation requests).

Beneficiary: Last name, First name, Beneficiary ID #, Date of Birth, Gender
Prescriber: Prescribing provider NPI #, Requester contact name, Phone, Ext.
Drug: Name, Strength, Quantity per 30 days, Length of therapy (select from provided intervals)

Step Therapy

Step Therapy Inquiry

The form asks whether the beneficiary had a prior trial of an alternative method to manage the condition. Document any prior therapies tried and outcomes. This step-therapy inquiry informs whether prior alternatives were attempted before this medication.

Indicate prior trial of alternative methods: Yes/No
Provide details of prior therapies and duration/outcome if Yes

Documentation Required

Required Clinical Documentation

Attach required clinical documentation with the request. Baseline assessment using Abnormal Involuntary Movement Scale (AIMS) or Extrapyramidal Symptom Rating Scale (ESRS) must be submitted. For continuation requests, include documentation showing improvement from baseline. Also indicate concurrent use of other VMAT2 inhibitors or contraindicated medications (MAOI or reserpine).

Attach baseline AIMS or ESRS evaluation (Yes/No)
For continuation: documentation showing improvement from baseline
Document concurrent VMAT2 inhibitor use (Yes/No) and concurrent MAOI or reserpine use (Yes/No)

Denial Risk

Documentation Triggers and Denial Risk

Missing required items may trigger a request for additional information or denial. Failure to provide baseline AIMS/ESRS, lack of prescriber signature/date, incomplete beneficiary or drug fields, or failure to document prior therapy or concurrent contraindicated medications are common triggers for denial or delays.

Missing baseline AIMS/ESRS evaluation may result in denial or request for more information
Absent prescriber signature/date is mandatory and may trigger denial
Incomplete beneficiary, prescriber, or drug information can delay processing or lead to denial
Failure to document prior trial of alternatives or concurrent contraindicated medications may increase denial risk

Coding & Duration Options

Length of therapy options

Initial request durationsup to 30, 60, 90, 120, or 180 days

Continuation request durationsup to 30, 60, 90, 120, 180, or 365 days

Form field for length of therapyProvider selects Initial or Continuation and chooses one of the listed day options

Step Therapy

Step	Question on form	Provider action required
1	Has the beneficiary had a previous trial of an alternative method to manage the condition? (Yes / No)	Provider must indicate prior trial status by selecting Yes or No on the form.
2	Is the beneficiary receiving dual therapy with other vesicular monoamine transporter 2 (VMAT2) inhibitors? (Yes / No)	Provider must disclose concurrent VMAT2 inhibitor therapy by selecting Yes or No.
3	Is the beneficiary concurrently using a MAOI or reserpine? (Yes / No)	Provider must disclose concurrent MAOI or reserpine use by selecting Yes or No.

Definitions

Baseline evaluation

Required baseline assessment toolsAbnormal Involuntary Movement Scale (AIMS) or Extrapyramidal Symptom Rating Scale (ESRS)

Timing of assessmentAssessment must be submitted along with the request prior to initiating therapy

Form confirmationProvider must indicate Yes/No that documented baseline evaluations using AIMS or ESRS are submitted

Continuation documentation

Continuation documentation requiredAttach documentation indicating the beneficiary has had improvement in symptoms from baseline for continuation requests

Prescriber signaturePrescriber signature and date required certifying the information (mandatory)

Form fieldFor continuation, form includes statement to attach improvement documentation and a prescriber signature block

Quantity Limits

Quantity per 30 Days

Quantity per 30 daysFree-text field on the form for provider to specify quantity per 30 days

Unit contextQuantity applies on a per month (30 days) basis as captured on the Drug Information section

Association with length of therapyQuantity per 30 days is submitted alongside drug name, strength, and requested length of therapy

Background

Tardive dyskinesia is described on the form as the target condition for treatment requests and is characterized as an involuntary movement disorder that requires clinical assessment. The form specifically requires confirmation that the beneficiary has a diagnosis of moderate to severe Tardive Dyskinesia and that the beneficiary is age 18 or older before an authorization can be considered. Clinical severity and response must be documented using standardized scales: the form requests a baseline evaluation using the Abnormal Involuntary Movement Scale (AIMS) or the Extrapyramidal Symptom Rating Scale (ESRS), and for continuation requests it requires attached documentation showing improvement from that baseline along with the prescriber’s signature.