Medicare AdvantagePrior AuthMedium impact
Onpattro® (patisiran) (Revised)
Humana·KY, SC · Neurology, Internal Medicine, Genetics·Medicaid
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for Onpattro® (patisiran) effective March 25, 2026, for Medicare and Medicaid members in Kentucky and South Carolina. The policy maintains four strict approval criteria: TTR gene mutation documentation, confirmed polyneuropathy with other causes ruled out, polyneuropathy disability score IIIb or lower, and no prior liver transplant history. Billing teams must ensure all prior authorization requests include these four clinical criteria before claim submission to avoid denials.
Action Required
By March 25, 2026: Billing team must update prior authorization workflows to require documentation of all four approval criteria before submitting Onpattro claims for Kentucky and South Carolina Medicaid and Medicare members. Create a pre-submission checklist including: (1) TTR gene mutation confirmation, (2) neurologic examination results ruling out other neuropathy causes, (3) polyneuropathy disability score IIIb or lower documentation, and (4) confirmation of no prior liver transplant. Providers must document these items in the medical record and include on prior authorization requests. Update claim submission protocols to flag missing documentation. Without all four criteria met, claims will be denied. Coordinate with clinical staff and providers to ensure compliance. Reference policy revision date 3/25/2026 when submitting requests.