Subject: Somavert 2097-A SGM P2024
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and compendial uses are
considered a covered benefit provided that all the approval criteria are met and the member
has no exclusions to the prescribed therapy.
FDA-Approved Indication
Somavert is indicated for the treatment of acromegaly in patients who have had an inadequate
response to surgery or radiation therapy, or for whom these therapies are not appropriate.
All other indications are considered experimental/investigational and not medically necessary.
II. DOCUMENTATION
Submission of the following information is necessary to initiate the prior authorization review:
A. For initial approval: Laboratory report indicating high pretreatment insulin-like growth factor-
1 (IGF-1) level and chart notes indicating an inadequate or partial response to surgery or
radiotherapy or a clinical reason for not having surgery or radiotherapy
B. For continuation: Laboratory report indicating normal current IGF-1 levels or chart notes
indicating that the member’s IGF-1 level has decreased or normalized since initiation of
therapy
III. CRITERIA FOR INITIAL APPROVAL
Acromegaly
Authorization of 12 months may be granted for the treatment of acromegaly when all of the
following criteria are met:
A. Member has a high pretreatment IGF-1 level for age and/or gender based on the laboratory
reference range.
B. Member had an inadequate or partial response to surgery or radiotherapy OR there is a
clinical reason why the member has not had surgery or radiotherapy.
IV. CONTINUATION OF THERAPY
Authorization of 12 months may be granted for continuation of therapy for acromegaly when
the member’s IGF-1 level has decreased or normalized since initiation of therapy.
Place of Service:
Outpatient
The above policy is based on the following references:
- Somavert [package insert]. New York, NY: Pharmacia & Upjohn Company LLC; July 2023.
- Katznelson L, Laws ER, Melmed S, et al. Acromegaly: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014; 99:3933-3951.
- American Association of Clinical Endocrinologists Acromegaly Guidelines Task Force. Medical guidelines for clinical practice for the diagnosis and treatment of acromegaly – 2011 update. Endocr Pract. 2011;17(suppl 4):1-44.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
April 17, 2024
