Medicare AdvantagePrior AuthMedium impact
Ampyra® (dalfampridine) (Revised)
Humana·Neurology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Ampyra (dalfampridine) for multiple sclerosis, effective January 1, 2020, with the most recent revision dated September 24, 2025. The policy requires prior authorization and establishes three approval criteria (MS diagnosis, ambulatory status, significant walking impairment) and two exclusions (seizure history and moderate-to-severe renal impairment). No substantive clinical changes from previous versions are documented in this revision.
Action Required
By September 24, 2025: Billing and clinical teams must verify this is the current Ampyra policy version in all systems and confirm prior authorization processes align with the three approval criteria (MS diagnosis, ambulatory status, significant walking impairment) and two exclusions (seizure history, CrCl <50 mL/min). Update clinical decision support tools and prior authorization software to enforce these criteria. When submitting Ampyra claims for Medicare Advantage members, billing staff must confirm documentation of all three approval criteria before claim submission. Do not process claims for members meeting either exclusion criterion. Reference the current policy at the provided URL (https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a40169c) rather than printed or cached versions. Prior authorization denials will result if these criteria are not met or documented.