Medicare AdvantagePrior AuthLow impact
Brineura™ (cerliponase alfa) (Revised)
Humana·KY, SC · Pediatrics, Neurology, Pharmacy·Medicaid
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Brineura™ (cerliponase alfa) prior authorization policy for rare pediatric CLN2 disease treatment. The policy now applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina lines of business. No specific billing code changes are documented, but this ultra-rare orphan drug requires strict prior authorization compliance with three clinical criteria before coverage.
Action Required
By March 25, 2026: Billing team must ensure all Brineura (cerliponase alfa) claims for Kentucky and South Carolina Medicaid members and Medicare beneficiaries route through prior authorization before submission. Verify that requests include: (1) confirmed CLN2 disease diagnosis with TPP1 deficiency testing documentation, (2) CLN2 Clinical Rating Scale score of 3 or higher documenting disease severity, and (3) confirmation that administration is by or under direction of a physician experienced in intraventricular administration. Update claim submission workflow to block claims without prior auth approval. Contact Humana's PAL (Preauthorization and Notification List) at www.humana.com/PAL for applicable medical and procedural coding. Claims submitted without prior authorization will be denied.