160 Form

Scenesse (afamelanotide) for Treatment of Erythropoietic Protoporphyria (EPP) Prior Authorization Request Form #160

Medical Policy #077 Scenesse (afamelanotide) for Treatment of Erythropoietic Protoporphyria (EPP)

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for Scenesse must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for Scenesse (160) using Authorization Manager.

For out of network providers: Requests should still be faxed to 888-973-0726.

Patient Information Patient Name and DOB:

Today’s Date: BCBSMA ID#:

Date of Treatment:

Physician Information Facility Information Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI#:

All of the following criteria must be met:

History of phototoxic reaction with sun exposure, AND  No evidence of significant liver involvement, AND  Biochemically confirmed diagnosis of protoporphyria (total protoporphyrin level >500ug/dl, AND 

• 2 -

  The prescriber is a specialist in the area of the patient’s diagnosis (eg., dermatology), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis. 

  Retreatment is evaluated on an annual basis and may be medically necessary when all of the following criteria are met:

  Increase in pain free time during light/sun exposure, AND  Reduction in number of phototoxic reactions or decrease in severity of phototoxic reactions from pretreatment baseline.
  