Download Mecasermin (Increlex®)

REVIEW REQUEST FOR
Mecasermin (Increlex®)
Provider Data Collection Tool Based on Medical Policy DRUG.00086
Policy Last Review Date:
Request Date:
/
Initial Request
Buy and bill
05/05/2016
Policy Effective Date:
06/28/2016
Provider Tool Effective Date:
06/28/2016
/
Subsequent Request
Individual’s Name:
Date of Birth:
/
/
Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
Diagnosis Code(s) (if known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Individual’s Height
(in) (cm)
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Place of Service:
Home
Office
Dialysis Center
Outpatient Hospital
Ambulatory Infusion
Ambulatory Infusion Center
Other:
Drug Name/HCPCS Code (if known)
Dose to be administered:
(mg)
Mecasermin (Increlex®)
J2170
(Other)
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
/
/
Duration:
Start Date For This Request:
(Weeks)
/
/
This medical policy base data collection tool is for a medical necessity review request for use of mecasermin
(Increlex®) for the treatment of conditions related to IGF-1 deficiency (IGFD) and other forms of growth hormone
insensitivity.
Please check all that apply to the individual:
Individual is greater than 2 years of age
Request is for initial treatment with mecasermin (Increlex®)
Individual is a child diagnosed with growth failure and a severe primary IGF-1 deficiency
(If checked, mark all of the following medical record evidence that supports the individual’s diagnosis)
Height standard deviation (SD) score is less than or equal to –3.0
Basal IGF-1 standard deviation score is less than or equal to –3.0
Growth hormone (GH) levels are normal or elevated (that is, GH levels are greater than 10 ng/ml on
standard GH stimulation tests) are present [see DRUG.00009 for additional information]
Individual is a child with a growth hormone gene deletion who has developed neutralizing antibodies to GH
Mecasermin (Increlex®)Provider Data Collection Tool Based on Medical Policy DRUG.00086
Policy Last Review Date:
05/05/2016
Policy Effective Date: 06/28/2016
Provider Tool Effective Date:
06/28/2016
Request is for continued treatment with mecasermin (Increlex®) in an individual diagnosed with growth
failure and a severe primary IGF-1 deficiency
Growth velocity is equal to or greater than 2 cm total growth in 1 year
Final adult height has NOT been reached
Individual has closed epiphyses
Individual has a suspected or diagnosed malignancy
Individual has secondary severe primary IGF-1 deficiency (IGFD) (for example, due to GH deficiency, untreated
malnutrition, untreated hypothyroidism or other causes).
Other Use(s) (Please list the use; and submit all supporting documents including labs, progress notes, imaging,
etc., for review.)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
/
Name & Title of Provider or Provider Representative Completing Form
& attestation (Please Print)*
/
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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