Summary
UnitedHealthcare's Community Plan Medicaid medical policy on Maximum Dosage and Frequency is revised effective 2026-12-01: the list of maximum allowed quantities and frequencies by HCPCS units is updated, with Exdensur (depemokimab) and Spinraza (nusinersen) added and HCPCS J2326 and J2361 added, and descriptions of Q5136 and Q5157 revised. Billing teams should confirm that claims for these drugs stay within the listed per-administration and frequency limits, using the applicable body-surface-area, weight, or fixed maximum for each patient.
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What to do
Action · 3 steps
01Before 2026-12-01: Billing team should review the revised maximum allowed quantities and frequencies by HCPCS units for Medicaid members, add the new codes J2326 and J2361 (Exdensur and Spinraza) and the revised Q5136 and Q5157 descriptions to the charge master and charge entry, and set claim edits so units above the listed maximums are caught before submission.
02Providers and front desk staff should be told that administrations beyond the stated maximum dosage or frequency for these medications are considered unproven and not medically necessary, so orders should be reviewed against the limits when scheduling.
03Claims exceeding limits will be denied per the policy, so appeal or resubmit with supporting documentation (such as patient weight over 140 kg or body surface area over 2.71 m2 where applicable) if the patient's size justifies additional units.
Codes mentioned
J2326J2361Q5136Q5157
Original notice
Maximum Dosage and Frequency
uhcprovider.com · Always check the source before changing claims.
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