Medicare AdvantageDocumentationMedium impact
MA08.063i, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb (Poherdy)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
Jul 27, 2026
We identified it
Jul 28, 2026
Summary
Medicare Advantage policy MA08.063i updates medical necessity criteria and medical coding requirements for pertuzumab (Perjeta®) and the biosimilar pertuzumab-dpzb (Poherdy®). The billing team must review the specific medical necessity criteria and ensure claims are coded and submitted according to the updated guidance effective immediately.
Action Required
By July 27, 2026: Billing team must obtain and review the full policy text for MA08.063i to identify specific medical necessity criteria changes and any billing code updates for pertuzumab and pertuzumab-dpzb. Update claim submission procedures, prior authorization templates, and provider documentation requirements accordingly. Communicate changes to oncology providers and infusion centers. Ensure all pertuzumab claims submitted after the effective date comply with new medical necessity documentation standards. Claims submitted without updated medical necessity documentation may be denied.