Medicare AdvantagePrior AuthMedium impact
Esbriet® (pirfenidone) (Revised)
Humana·Pulmonology, Internal Medicine, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a revision (updated January 28, 2026) to Humana's Medicare Advantage prior authorization policy for Esbriet® (pirfenidone) for idiopathic pulmonary fibrosis treatment. The policy requires documentation of pulmonary fibrosis via CT scan showing usual interstitial pneumonia (UIP) or surgical lung biopsy, plus exclusion of alternative diagnoses before approval. No substantive coverage changes are noted in this revision; this appears to be a routine policy refresh.
Action Required
Immediately: Billing and prior authorization teams must ensure all Esbriet/pirfenidone requests for Medicare Advantage members include (1) documentation of pulmonary fibrosis confirmed by CT scan with UIP pattern OR surgical lung biopsy, and (2) provider attestation that member has NO clinically significant environmental exposure or secondary causes (e.g., asbestos, radiation, sarcoidosis, HIV, hepatitis, drug-induced, hypersensitivity pneumonitis). Update prior authorization intake forms and EMR templates to require collection of CT/biopsy reports and exclusion checklist. Train front desk and clinical staff to request these documents before submitting PA requests. Emphasize to providers that claims lacking imaging/biopsy documentation or showing alternative diagnoses will be denied. Reference the Humana Preauthorization and Notification List (PAL) at www.humana.com/PAL for any medically-billed coding requirements.