MedicaidPrior AuthHigh impact
Xgeva® (denosumab) and biosimilars (Revised)
Humana·LA · Oncology, Hematology, Palliative Care·Medicaid
Effective date
Jan 1, 2024
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Xgeva (denosumab) and six biosimilars effective January 1, 2024, with a revision date of May 1, 2026. The policy covers four indications—hypercalcemia of malignancy, osteolytic bone metastases, multiple myeloma, and giant cell tumor of bone—each with specific clinical criteria and a critical exclusion: concurrent bisphosphonate therapy is not permitted. Billing teams must ensure prior authorization is obtained before claims are submitted and verify all clinical criteria are met.
Action Required
By January 1, 2024 (or immediately if claims are already being submitted): (1) Billing team must implement prior authorization requirement in billing system for Xgeva and all six biosimilars (Wyost, Osenvelt, Bomyntra, Bilprevda, Xtrenbo) for Louisiana Medicaid members. (2) Update claim submission workflows to require prior authorization before processing—claims submitted without authorization will be denied. (3) Providers must document one of four indications and meet specific clinical criteria before requesting authorization: (a) Hypercalcemia of malignancy: albumin-corrected calcium >12.5 mg/dL AND prior IV bisphosphonate therapy failure/intolerance/contraindication; (b) Osteolytic bone metastases: solid tumor diagnosis AND documented bone metastases AND prior bisphosphonate therapy failure/intolerance/contraindication (exception: not required for prostate cancer); (c) Multiple myeloma: MM diagnosis AND prior bisphosphonate therapy failure/intolerance/contraindication; (d) Giant cell tumor of bone: GCTB diagnosis only (no prior therapy requirement). (4) Critical: Flag and deny any claims showing concurrent bisphosphonate use (zoledronic acid or pamidronate)—this is an absolute exclusion for all four indications. (5) Front desk and clinical staff must ensure patient charts document corrected calcium levels, prior bisphosphonate therapy history, and reason for switch before PA request is submitted. Failure to obtain prior authorization will result in claim denials for Louisiana Medicaid members.