Start free

PolicyChanges tracks payer policy changes for medical practices and tells you what to do before they take effect.

Create a free accountPolicy Monitoring is free. No card required.
← Back to list
HumanaMedicare Advantage · Prior Auth · Medicaid · FL, KY, SC, VA · Oncology, HematologyMedium impact

Margenza (margetuximab-cmkb) (Revised)

Act
by Sep 24, 2025
Effective date
Sep 24, 2025
Identified
Jun 25, 2026

Summary

Humana revised its Margenza (margetuximab-cmkb) prior authorization policy effective September 24, 2025. The policy maintains coverage for metastatic HER2-positive breast cancer patients who have received at least 2 prior anti-HER2 regimens (with one in metastatic setting) and are receiving Margenza in combination with specific chemotherapy agents. The revision date change suggests updates to clinical criteria, references, or administrative requirements—review the full policy against your previous version to identify specific differences.

Get alerts when payers change rules like this one

We check Humana and other payers every day and email you when a change matches your specialty and state.

Get Humana alertsPolicy Monitoring is free. No card required.

What to do

by Sep 24, 2025 · 7 steps
01Billing and clinical teams must obtain prior authorization for all Margenza claims before submission—do not bill without approval.
02Verify that patient meets ALL four criteria: metastatic breast cancer diagnosis, HER2 neu positive status (per ASCO-CAP guidelines), prior receipt of two anti-HER2 therapies (one in metastatic setting), and Margenza combined with approved chemotherapy (gemcitabine, eribulin, vinorelbine, or capecitabine).
03Document HER2 status testing results (IHC 3+, IHC 2+ with ISH confirmation, or ISH results meeting specified thresholds) in the patient record before requesting authorization.
04Update clinical staff workflows to screen for the exclusion: deny coverage requests if disease progression occurs on Margenza.
05Ensure prior auth requests reference the September 24, 2025 revision date to confirm you are using current policy.
06Claims submitted without prior authorization or failing to meet all four criteria will be denied.
07Flag for your Medicaid compliance team: policy applies to Florida, Kentucky, South Carolina, and Virginia Medicaid plans.

Original notice

Margenza (margetuximab-cmkb) (Revised)
mcp.humana.com · Always check the source before changing claims.
View original ↗

Related changes

See all Humana changes →
Margenza (margetuximab-cmkb) (Revised)MediumEffective Nov 1, 2025 · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumEffective Nov 1, 2025 · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumEffective Nov 1, 2025 · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumNo effective date · MedicaidBrowse every Humana change in the policy list

Related policy hubs

Humana policiesFL policy changesKY policy changesSC policy changesVA policy changesOncologyHematology

Summaries are AI-assisted. Always confirm against the original payer notice.

What is PolicyChanges

One workspace for payer rules, prior auth, coding and compliance

Medical practices use PolicyChanges to catch payer changes before they cause denials. Every change is summarized in plain English, with the codes involved, the date it takes effect and what to do.

Policy MonitoringPayer policy, prior auth and coding changes, filtered to your saved searchesOIG ScreeningStaff and vendors screened every month against OIG LEIE, SAM.gov and state Medicaid listsPrior Auth LookupKnow if a service needs prior authorization before you schedule itCredentialing TrackerLicenses, CAQH, Medicare revalidation and payer enrollments, with reminders before anything lapsesCompliance CenterKeep your HIPAA program documented and ready to show
Start freePolicy Monitoring is free. No card required.
Get alerts for changes like thisPolicy Monitoring is free. No card required.Create a free account