CommercialPrior AuthMedium impact
Difelikefalin (Korsuva) Injection (CPB 1028, reviewed 2025-12-23)
Aetna·Nephrology, Pharmacy·Pharmacy
Effective date
Dec 23, 2025
We identified it
Aug 13, 2026
Summary
Aetna has issued a new clinical policy (CPB 1028, effective 2025-12-23) establishing coverage criteria for Difelikefalin (Korsuva) injection for moderate-to-severe pruritus in hemodialysis patients. The policy requires precertification, nephrology consultation, documented treatment failure of alternative therapies, and clinical response monitoring. Coverage excludes peritoneal dialysis patients.
Action Required
By 2025-12-23, the billing team must: (1) Update billing system rules to require precertification for all Difelikefalin (Korsuva) claims using HCPCS code J0879 before submission to Aetna; (2) Configure system to flag claims for members on peritoneal dialysis and deny automatically as non-covered; (3) Create precertification checklist requiring documentation of: patient age ≥18, current hemodialysis status, baseline pruritus scoring (WI-NRS, VAS, or NRS), confirmation pruritus is not dialysis-session-only, failed/contraindicated trials of antihistamines/gabapentin/pregabalin/emollients, and dosage ≤0.5 mcg/kg per treatment (max 3/week); (4) Update encounter templates to require nephrology prescription/consultation; (5) Configure continuation-of-therapy rules to require documentation of ≥4-point improvement on WI-NRS from baseline; (6) Provide precertification contact information to providers (call 866-752-7021 or fax 888-267-3277); (7) Train billing and prior auth teams on these requirements. Claims submitted without precertification or missing required documentation will be denied.