Medicare AdvantagePrior AuthMedium impact
Gene Therapy Treatments for Sickle Cell Disease - Medicare Advantage (Revised)
Humana·Hematology, Oncology, Transplant Surgery·Medicare Advantage
Effective date
Feb 2, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has established new coverage criteria for two gene therapy treatments for sickle cell disease - Casgevy and Lyfgenia. Both require medical director review and specific clinical criteria including age 12-65, history of severe vaso-occlusive crises, and lack of available matched donor for stem cell transplant.
Action Required
Before February 2, 2026: Billing team must contact Corporate Transplant Department at 1-866-421-5663 for all Casgevy and Lyfgenia requests, as both require medical director review. Update billing system to flag codes J3392, J3394, XW133J8, XW143J8, XW133H9, XW143H9 for prior authorization. Ensure documentation includes patient age (12-65), history of severe VOCs/VOEs as specified, and confirmation of lack of matched donor availability.