Start free

PolicyChanges tracks payer policy changes for medical practices and tells you what to do before they take effect.

Create a free accountPolicy Monitoring is free. No card required.
← Back to list
HumanaMedicaid · Prior Auth · Medicaid · OH · OncologyMedium impact

Margenza (margetuximab-cmkb) (Revised)

Act
by Nov 1, 2025
Effective date
Nov 1, 2025
Identified
Sep 26, 2026

Summary

Humana Medicaid Ohio has revised its prior authorization policy for Margenza (margetuximab-cmkb), a HER2-positive metastatic breast cancer treatment. The policy requires prior authorization and specifies that coverage applies only to patients with metastatic HER2-positive breast cancer who have received at least two prior anti-HER2 therapies (with one in the metastatic setting) and are receiving Margenza in combination with specific chemotherapy agents. Claims will be denied if the patient experiences disease progression on Margenza.

Get alerts when payers change rules like this one

We check Humana and other payers every day and email you when a change matches your specialty and state.

Get Humana alertsPolicy Monitoring is free. No card required.

What to do

by Nov 1, 2025 · 6 steps
01Billing team must update system to require prior authorization for Margenza (margetuximab-cmkb) HCPCS code J9348 for all Medicaid Ohio claims.
02Establish clinical criteria validation in billing workflow: verify member has metastatic HER2-positive breast cancer, has received minimum two prior anti-HER2 therapies (at least one in metastatic setting), and is receiving combination chemotherapy (gemcitabine, eribulin, vinorelbine, or capecitabine).
03Update prior authorization submission templates to require HER2 testing documentation per 2018 ASCO-CAP guidelines (IHC 3+, IHC 2+ with ISH confirmation, or ISH results).
04Configure system to flag and deny claims if disease progression on Margenza is documented.
05Train billing staff to reject claims missing required clinical documentation.
06Update encounter forms and provider alerts to communicate new requirements.
If missed: Failure to obtain prior authorization or submit incomplete clinical documentation will result in claim denials.

Codes mentioned

J9348

Original notice

Margenza (margetuximab-cmkb) (Revised)
mcp.humana.com · Always check the source before changing claims.
View original ↗

Related changes

See all Humana changes →
Margenza (margetuximab-cmkb) (Revised)MediumEffective Nov 1, 2025 · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumEffective Nov 1, 2025 · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumNo effective date · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumEffective Sep 24, 2025 · MedicaidBrowse every Humana change in the policy list

Related policy hubs

Humana policiesOH policy changesOncologyCode J9348

Summaries are AI-assisted. Always confirm against the original payer notice.

What is PolicyChanges

One workspace for payer rules, prior auth, coding and compliance

Medical practices use PolicyChanges to catch payer changes before they cause denials. Every change is summarized in plain English, with the codes involved, the date it takes effect and what to do.

Policy MonitoringPayer policy, prior auth and coding changes, filtered to your saved searchesOIG ScreeningStaff and vendors screened every month against OIG LEIE, SAM.gov and state Medicaid listsPrior Auth LookupKnow if a service needs prior authorization before you schedule itCredentialing TrackerLicenses, CAQH, Medicare revalidation and payer enrollments, with reminders before anything lapsesCompliance CenterKeep your HIPAA program documented and ready to show
Start freePolicy Monitoring is free. No card required.
Get alerts for changes like thisPolicy Monitoring is free. No card required.Create a free account