Medicare AdvantagePrior AuthMedium impact
Unituxin (dinutuximab) (Revised)
Humana·KY, SC · Oncology, Pediatrics·Medicaid
Effective date
Jun 24, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Unituxin (dinutuximab) pharmacy coverage policy for high-risk neuroblastoma patients, effective June 24, 2026. This is a prior authorization policy covering Medicare and Medicaid (Kentucky and South Carolina) that requires specific clinical criteria and combination therapy protocols. The revision updates documentation based on current clinical evidence and safety data.
Action Required
By June 24, 2026: Billing and clinical teams must implement updated prior authorization requirements for Unituxin (dinutuximab) claims. (1) Verify all six clinical criteria are met before submitting: patient age <18, high-risk neuroblastoma diagnosis, combination use with isotretinoin and alternating Leukine/Proleukin cycles, partial response to induction chemotherapy and surgery, prior myeloablative chemotherapy with ASCT, and prior radiation therapy. (2) Confirm medication is NOT being used as monotherapy and patient has NOT experienced disease progression on Unituxin (exclusion criteria). (3) Update prior authorization system in billing software to enforce these requirements and document oncologist prescription. (4) Train billing and clinical staff on the two exclusion criteria that trigger denial. (5) For Kentucky and South Carolina Medicaid claims, route to appropriate state program rules. Failure to obtain proper prior authorization or failure to verify all criteria will result in claim denials. Reference www.humana.com/PAL for medical coding information.