MedicaidPrior AuthMedium impact
MAB2019120403
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Hematology, Genetics +1 more·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) now requires prior authorization for all enzyme replacement therapies used to treat Gaucher disease, effective January 1, 2020. New clinical guidelines specify diagnostic requirements and specialist consultation requirements for both initial and renewal authorizations.
Action Required
By January 1, 2020: Billing team must update prior authorization requirements for all Gaucher disease enzyme replacement therapies for Pennsylvania Medicaid patients. Ensure prescriptions include documentation of enzyme assay or DNA testing confirming diagnosis, evidence of clinical symptoms (anemia, bone disease, hepatomegaly, etc.), and specialist consultation. For renewals, document improvement in disease severity. Claims will be denied without proper prior authorization.