Download Sandostatin ® / Sandostatin ® LAR Depot

REVIEW REQUEST FOR
Plan
Octreotide acetate (Sandostatin®/ Sandostatin® LAR Depot)
Provider Data Collection Tool Based on Clinical Guideline DRUG-45
Policy Last Review Date: 11/03/2016
Policy Effective Date:
Request Date:
/
/
Initial Authorization Request
Buy and bill
12/28/2016
Provider Tool Effective Date:
Subsequent Request
Individual’s Name:
Date of Birth:
/
/
Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
12/28/2016
Diagnosis Code(s) (if
known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Individual’s Height
(in) (cm)
Provider ID Number:
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering
Provider):
Provider ID Number:
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:
Sandostatin® J2353
J2354
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
/
/
Duration:
Start Date For This Request:
(Weeks)
/
/
(mg)
(mcg)
(Other)
This clinical guideline based data collection tool is for a medical necessity review request for
clinical use of octreotide acetate (Sandostatin®, and Sandostatin® LAR Depot) in the treatment
of acromegaly, carcinoid tumors, vasoactive intestinal peptide tumors, and off-label treatment for
other conditions.
Please check all of the following that apply to the individual.
REVIEW REQUEST FOR
Octreotide acetate (Sandostatin®/ Sandostatin® LAR Depot)
Plan
Provider Data Collection Tool Based on Clinical Guideline DRUG-45
Policy Last Review Date: 11/03/2016
Policy Effective Date:
12/28/2016
Provider Tool Effective Date:
12/28/2016
I. Acromegaly
Request is for octreotide acetate (Sandostatin®) for the treatment of an individual with
acromegaly (If checked, answer the following when it applies)
Individual has had an inadequate response to or cannot be treated with surgical
resection, pituitary irradiation, and bromocriptine mesylate at maximally tolerated
doses.
II. Carcinoid Tumors (Well-differentiated Neuroendocrine Tumors)
Request is for octreotide acetate (Sandostatin®) for the treatment of an individual with
carcinoid tumors (If checked, identify the appropriate treatment indication(s) below)
Metastatic carcinoid tumors
Carcinoid syndrome to suppress or inhibit severe diarrhea and flushing episodes
associated with the disease
Prophylactic administration prior to biopsy in an individual with a suspected
functioning carcinoid tumor
Prophylactic administration prior to induction of anesthesia in an individual with a
functional carcinoid tumor
Prophylactic administration preoperatively to a surgical procedure in an
individual with a functional carcinoid tumor.
Request is for supplemental use of short-acting Sandostatin® for rapid relief of symptoms
or for breakthrough symptoms in an individual with carcinoid tumors while taking longacting octreotide acetate (Sandostatin® LAR Depot)
III. Other Neuroendocrine Tumors
Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an
individual with neuroendocrine tumors.
Request is for supplemental use of short-acting Sandostatin® for rapid relief of symptoms
or for breakthrough symptoms in an individual with carcinoid tumors while taking
long-acting octreotide acetate (Sandostatin® LAR Depot)
(If EITHER of the above is checked, identify the appropriate treatment indication(s) below)
Management of unresectable locoregional disease or distant metastasis
As treatment of the profuse watery diarrhea associated with VIPomas
Treatment of underlying Zollinger-Ellison syndrome
Prophylactic treatment prior to surgery for gastrinoma
REVIEW REQUEST FOR
Octreotide acetate (Sandostatin®/ Sandostatin® LAR Depot)
Plan
Provider Data Collection Tool Based on Clinical Guideline DRUG-45
Policy Last Review Date: 11/03/2016
IV.
Policy Effective Date:
12/28/2016
Provider Tool Effective Date:
12/28/2016
Other Indications
Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an
individual with bleeding gastroesophageal (GE) varices
(If checked, mark the following that apply)
Gastroesophageal varices are associated with liver disease
Octreotide acetate will be used in combination with endoscopic therapy (that is, band
ligation or sclerotherapy) or alone if endoscopic therapy is not immediately available
Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an
individual with central nervous system (CNS) meningiomas that are surgically inaccessible,
recurrent, or progressive and the individual is not a candidate for further radiation therapy
Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an
individual with chemotherapy- or radiation-induced diarrhea that is unresponsive to
conventional antidiarrheal medications (for example, diphenoxylate and atropine or
loperamide)
Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an
individual with malignant bowel obstruction, to manage gastrointestinal (GI) symptoms
(such as nausea, pain, or vomiting).
Request is for supplemental use of short-acting Sandostatin® for rapid relief of
symptoms or for breakthrough symptoms in an individual with an OTHER
INDICATION while taking long-acting octreotide acetate (Sandostatin® LAR Depot)
Please specify the INDICATION: _____________________________
Request is for Sandostatin® or Sandostatin® LAR Depot for treatment of a condition not
specified above. (If checked, please check the applicable condition below and submit all
documentation to support the request)
Chylothorax in neonates
Diarrhea (severe, secretory) associated with acquired immunodeficiency syndrome
(AIDS)
Gastrointestinal (GI) tract conditions (If checked, mark the applicable condition below)
gastroparesis
pancreatitis
prevention of postoperative complications (for example, fistulae) following
pancreatic surgery
short bowel syndrome
upper GI bleeding (such as, non-variceal hemorrhage)
vascular (arteriovenous) malformations
Graves' ophthalmopathy
Hypothalamic obesity (control of hyperinsulinemia)
Other carcinomas (such as, advanced breast cancer, hepatocellular cancer, or prostate cancer)
Polycystic kidney disease
Other: _______________________________________________
REVIEW REQUEST FOR
Plan
Octreotide acetate (Sandostatin®/ Sandostatin® LAR Depot)
Provider Data Collection Tool Based on Clinical Guideline DRUG-45
Policy Last Review Date: 11/03/2016
Policy Effective Date:
12/28/2016
Provider Tool Effective Date:
12/28/2016
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I confirm that the information entered on this form is accurate and complete based on the records available at the
time of this request. I understand the health plan or its designees may request medical documentation to verify the
accuracy of the information reported on this form.
Name and Title of Provider or Provider Representative Completing
Form and 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.