Summary
Effective 2027-01-01, UnitedHealthcare Community Plan of New Mexico Medicaid expanded its denosumab policy: Jubereq and Osvyrti are preferred products covered under the Diagnosis-Specific Criteria, while Boncresa, Oziltus, and Ponlimsi are non-preferred and covered only when the Preferred Product Criteria and Diagnosis-Specific Criteria are both met. The postmenopausal osteoporosis criteria add a very-high-fracture-risk pathway for initial therapy, and HCPCS codes Q5166, Q5171, and Q5173 were added.
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What to do
Action · 3 steps
01By 2027-01-01: Billing team and providers should confirm which denosumab products the practice dispenses for New Mexico Medicaid members, and update charge entry so Q5166, Q5171, and Q5173 are available for the newly listed biosimilars.
02Before scheduling denosumab for postmenopausal osteoporosis, providers and front desk staff should document the diagnosis-specific criteria, including the very-high-fracture-risk indicators (recent fracture within 12 months, fracture on approved osteoporosis therapy, multiple fractures, fractures on drugs causing skeletal harm, BMD T-score below -3.0, high fall risk, or FRAX thresholds), in the chart so claims for non-preferred products such as Boncresa, Oziltus, or Ponlimsi include supporting documentation.
03Billing team should watch for the payer's next notice on any further product or criteria revisions.
Codes mentioned
Q5166Q5171Q5173
Original notice
Denosumab
uhcprovider.com · Always check the source before changing claims.
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