Medicare AdvantagePrior AuthLow impact
Mepsevii™ (vestronidase alfa-vjbk) (Revised)
Humana·KY, SC · Pediatrics, Genetics, Internal Medicine·Medicaid
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Mepsevii (vestronidase alfa-vjbk) prior authorization policy effective April 22, 2026, for Medicare and Medicaid members in Kentucky and South Carolina. The policy requires prior authorization for this rare enzyme replacement therapy used to treat Mucopolysaccharidosis VII (MPS VII/Sly syndrome). The primary approval criterion is confirmation of MPS VII diagnosis. Key safety requirement: Mepsevii must be administered under healthcare professional supervision due to black box warning for anaphylaxis risk.
Action Required
By April 22, 2026: Billing and prior authorization teams must ensure Mepsevii (vestronidase alfa-vjbk) claims for Kentucky and South Carolina Medicaid and Medicare members are routed through prior authorization process. Verify diagnosis of MPS VII (ICD-10: E76.29 or equivalent) is documented before claim submission. Clinical staff should confirm administration will occur under healthcare professional supervision with anaphylaxis management capability available. Visit www.humana.com/PAL to obtain current medical billing claim codes and preauthorization documentation requirements. Update claim denial review protocols to flag any Mepsevii claims submitted without prior authorization approval. Failure to obtain prior authorization will result in claim denials.