Summary
UnitedHealthcare Community Plan of Kentucky revised its FcRn Blockers medical benefit drug policy, effective 2027-01-01, to state that Imaavy is proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in adults and children 12 and older currently or previously treated with corticosteroids, subject to specified diagnostic, treatment-history, dosing and prescriber criteria. ICD-10 code D59.11 was added to the applicable codes, and the policy covers Imaavy, Rystiggo, Vyvgart and Vyvgart Hytrulo vial for administration by a healthcare professional.
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What to do
Action · 4 steps
01By 2027-01-01: For Kentucky Medicaid members with wAIHA, have the billing team confirm the diagnosis is supported in the chart with documented hemolytic anemia, a positive DAT or the negative-DAT workup, and signs consistent with wAIHA, and add ICD-10 D59.11 to the charge entry and claim edits for Imaavy infusions.
02Before scheduling Imaavy for these members, have the front desk and providers request prior authorization, confirming documentation of corticosteroid or immunosuppressant use or the trial-and-failure, contraindication or intolerance history, rituximab trial and failure, that Imaavy is not combined with rituximab or immune globulin for the same indication, FDA-labeled wAIHA dosing, and that the prescriber is a hematologist or works in consultation with one.
03Claims without prior authorization will be denied.
04Continuation requests need documentation of positive clinical response to Imaavy; initial and reauthorization approvals are limited to 12 months.
Codes mentioned
D59.11
Original notice
FcRn Blockers
uhcprovider.com · Always check the source before changing claims.
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