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Monoclonal Antibodies for Treatment of Alzheimer’s Disease
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Leqembi (lecanemab-irmb) may be considered medically necessary only when all initial or renewal criteria are met, and prior authorization is required. Leqembi is unproven and not medically necessary for any indication other than mild cognitive impairment due to Alzheimer's disease and mild Alzheimer's disease dementia. Kisunla (donanemab-azbt) and Leqembi IQLIK are considered not medically necessary because other formulary options are covered for Alzheimer's disease, and the policy history records this update on 07/01/2026.
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What to do
Action · 5 steps
01Billing team: Get prior authorization before billing Leqembi (lecanemab-irmb) under J0174, and confirm the chart supports each initial criterion, including an NIA-AA diagnosis of mild cognitive impairment or mild dementia due to Alzheimer's disease, PET or CSF evidence of amyloid, a qualifying CDR-GS with Memory Box, MMSE or MoCA score, ruled-out alternative causes, a baseline brain MRI, ApoE e4 status or documentation that the prescriber informed the individual of the ARIA risk, no listed intracerebral hemorrhage risk factors, no stroke or TIA in the previous 12 months, a specialist involved, and a dose within program quantity limits.
02Billing team: For renewals, confirm prior BCBSMS approval, documented improvement, stability or slowing on the same severity tool used at baseline and completed within 30 days before the renewal request, and ARIA MRI evaluation before the 5th, 7th and 14th infusions.
03Initial approvals run 6 months and renewal approvals run 12 months.
04Billing team: Do not bill Kisunla (donanemab-azbt) or Leqembi IQLIK as medically necessary, because the policy considers them not medically necessary.
05Consequence: Delivery or administration services not approved through the BCBSMS PA review process are considered not medically necessary, and use of samples does not count as current or stable therapy.
Codes mentioned
J0174J0175G30.0G30.9
Original notice
Monoclonal Antibodies for Treatment of Alzheimer’s Disease
bcbsms.com · Always check the source before changing claims.
Related changes
See all Blue Cross & Blue Shield of Mississippi changes →State and School Employees' Health Insurance Plan - Monoclonal Antibodies for Treatment of Alzheimer’s DiseaseHighNo effective date · Medical PolicySelected Positron Emission Tomography Technologies for Evaluation of Alzheimer DiseaseHighNo effective date · Medical PolicyMagnetic Resonance Imaging (MRI) of the Brain and HeadHighEffective Oct 1, 2026 · Medical PolicyGenetic Testing for Alzheimer DiseaseMediumNo effective date · Medical PolicyBrowse every Blue Cross & Blue Shield of Mississippi change in the policy list