MedicaidPrior AuthHigh impact
Leqembi® (lecanemab-irmb) (Revised)
Humana·KY, SC · Neurology, Geriatrics, Pharmacy·Medicaid
Effective date
Oct 22, 2025
We identified it
Jun 25, 2026
Summary
Humana has revised its Leqembi (lecanemab) prior authorization policy for Kentucky and South Carolina Medicaid members, effective October 22, 2025. The policy now requires comprehensive documentation including cognitive assessments (MMSE/MoCA scores), amyloid-beta pathology confirmation via PET scan/CSF/blood biomarkers, recent brain MRI with specific exclusion criteria, ApoE ε4 status assessment, and exclusion of alternative diagnoses. Prior authorization is required for all initial and renewal requests with strict renewal criteria including continued cognitive monitoring and scheduled MRIs before the 5th, 7th, and 14th infusion doses.
Action Required
By October 22, 2025: Billing and clinical teams must implement the following: (1) Establish a prior authorization checklist for all Leqembi requests requiring documentation of MMSE/MoCA scores (within 3 months), amyloid-beta pathology confirmation (PET scan, CSF biomarkers, or high-specificity blood-based biomarkers ≥90% sensitivity/specificity), recent brain MRI (within 1 year) with specific contraindications documented, and ApoE ε4 status with risk/benefit assessment; (2) Update billing system templates to require submission of cognitive test reports, imaging reports, and medical records from most recent office visit before claim submission; (3) Providers must confirm diagnosis of MCI or mild dementia stage (MMSE 22-30 or MoCA 17-30) and prescriber experience (neurologist/geriatric specialist); (4) Screen for exclusion criteria: anticoagulant use (except aspirin/antiplatelet), seizure/stroke/TIA within 12 months, and MRI findings (>4 microhemorrhages, single microhemorrhage >10mm, superficial siderosis, vasogenic edema, >2 lacunar infarcts, Fazekas score 3, ABRA, CAA-ri); (5) For renewal requests every 6 months, verify member has not progressed to moderate dementia (MMSE <22 or MoCA <17), confirm follow-up MRIs performed before 5th, 7th, and 14th doses with results submitted, and attest no ARIA clinical signs if >6 months since last MRI; (6) Confirm consistent on-schedule infusion delivery at appropriate 10mg/kg dose. Failure to obtain prior authorization or submit required documentation will result in claim denials. Kentucky and South Carolina Medicaid billing staff must implement immediately; other state programs are not affected.