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08.00.82r, Ustekinumab for Intravenous Infusion
Act
by Sep 21, 2026
Effective date
Sep 21, 2026
Identified
Sep 22, 2026
Summary
Policy 08.00.82r establishes coverage and medical necessity criteria for Ustekinumab (Stelara) administered via intravenous infusion. This is a new or significantly revised policy affecting pharmacy coverage, reimbursement positions, and required clinical documentation for this biologic immunosuppressant. The billing team must implement new prior authorization requirements and medical necessity validation protocols immediately.
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What to do
by Sep 21, 2026 · 5 steps
01Billing team must implement prior authorization workflow in the billing system for all Ustekinumab IV infusion claims—configure system to flag claims requiring medical necessity documentation before submission.
02Update claim submission protocols to require documented medical necessity criteria as defined in policy 08.00.82r before billing.
03Train billing and clinical staff on new medical necessity requirements specific to IV Ustekinumab administration.
04Establish verification process with pharmacy department to confirm patient eligibility and authorization status before infusion scheduling.
05Add policy reference (08.00.82r) to all claim notes and prior auth requests.
If missed: Failure to obtain prior authorization and medical necessity documentation will result in claim denials and potential recoupment.
Original notice
08.00.82r, Ustekinumab for Intravenous Infusion
medpolicy.ibx.com · Always check the source before changing claims.