Medicare AdvantagePrior AuthMedium impact
Kanuma® (sebelipase alfa) (Revised)
Humana·KY, SC, VA · Genetics, Pediatrics, Internal Medicine +2 more·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Kanuma® (sebelipase alfa) prior authorization policy effective September 24, 2025, for treatment of Lysosomal Acid Lipase Deficiency (LAL-D) across Medicare, Medicaid-Kentucky, Medicaid-South Carolina, and Medicaid-Virginia. The policy maintains the single clinical criterion requiring confirmed LAL-D diagnosis via Dried Blood Spot (DBS) test, leucocyte testing, or genetic testing, with approval granted in plan year durations or through clinical review.
Action Required
By September 24, 2025: Billing team must update prior authorization workflows in the system to reflect this revised policy. 1) Verify that prior authorization requirement for Kanuma intravenous solution is active in billing software for affected plan types (Medicare and specified Medicaid states). 2) Ensure that claims for Kanuma submissions include documented evidence of LAL-D diagnosis confirmation (DBS test, leucocyte testing, or genetic testing results). 3) Communicate to providers that initial and renewal approvals will be processed in plan year durations or determined through clinical review - no specific dosing or frequency limits are specified in this policy. 4) Update internal documentation to reference the September 24, 2025 revision date when responding to provider inquiries. Failure to obtain prior authorization will result in claim denials. Reference the policy at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a434340 for current guidance.