CommercialPrior AuthMedium impact
Lumasiran (Oxlumo) (CPB 0983, reviewed 2026-02-17)
Aetna·Genetics, Nephrology, Urology +1 more·Medical Policy
Effective date
Feb 17, 2026
We identified it
Aug 16, 2026
Summary
Aetna has established a new clinical policy (CPB 0983, effective 2026-02-17) for lumasiran (Oxlumo) coverage in primary hyperoxaluria type 1 (PH1) patients. The policy requires precertification for all claims, restricts prescribing to geneticists/nephrologists/urologists, and mandates specific diagnostic confirmation and laboratory testing prior to authorization. This is a gene therapy product requiring dedicated review by Aetna's GCIT team.
Action Required
By 2026-02-17: (1) Billing team must implement mandatory precertification requirement for all lumasiran (Oxlumo) claims via Aetna GCIT team by calling (866) 752-7021 or faxing (888) 267-3277 before claim submission. (2) Update billing software to flag CPT 96372 and HCPCS J0224 claims for Aetna commercial plans requiring prior authorization documentation. (3) Establish verification workflow to confirm prescriber specialty (geneticist, nephrologist, or urologist) before processing claims. (4) Create precertification checklist requiring: molecular genetic testing for AGXT gene mutations OR liver enzyme analysis confirming absent/reduced AGT activity, elevated urinary oxalate/plasma oxalate levels, and confirmation patient has NOT received prior liver transplant and will NOT receive concurrent nedosiran (Rivfloza). (5) Front office and billing staff must attach Statement of Medical Necessity (SMN) form to all requests. (6) Update encounter forms and provider communication to alert prescribers of precertification requirement. Claims submitted without precertification or missing required diagnostic documentation will be denied by Aetna.