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UnitedHealthcareMedicaid · Prior Auth · Medical Benefit Drug Policy · NM · Hematology, Pharmacy, Rheumatology +1 moreMedium impact

FcRn Blockers

Effective date
Jan 1, 2027
Identified
Nov 7, 2026

Summary

Effective 2027-01-01, UnitedHealthcare Community Plan of New Mexico (Medicaid) revised its FcRn Blockers medical benefit drug policy to state that Imaavy (nipocalimab-aahu) is proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in adults and children 12 and older who currently or previously received corticosteroids, with added ICD-10 code D59.11. Billing teams should align prior authorization requests, documentation and charge entry for Imaavy and the other listed FcRn blocker products (Rystiggo, Vyvgart, Vyvgart Hytrulo IV/SC vial) with the revised criteria.

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What to do

Action · 2 steps
01By 2027-01-01: Billing team and providers should update prior authorization submissions for Imaavy for wAIHA in New Mexico Community Plan members, confirming documentation of a hemolytic anemia diagnosis (positive DAT, or negative DAT with other causes ruled out), wAIHA signs and symptoms, current or prior corticosteroid treatment, rituximab trial/failure/contraindication/intolerance, hematologist prescribing or consultation, and no concurrent rituximab or immune globulin for the same indication.
02Update charge entry and claim diagnosis fields to include ICD-10 D59.11 where applicable, and tell providers and front desk staff about the revised continuation criteria requiring documented positive clinical response for renewals, with initial authorizations 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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Related changes

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Related policy hubs

UnitedHealthcare policiesNM policy changesHematologyPharmacyRheumatologyNeurologyCode D59.11

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