Summary
UnitedHealthcare Community Plan of New Mexico revised its Maximum Dosage and Frequency medical policy, updating the list of maximum allowed quantities and frequencies by HCPCS units, adding Exdensur (depemokimab) and Spinraza (nusinersen), adding HCPCS codes J2326 and J2361, and revising the descriptions of Q5136 and Q5157. Billing teams should check claim quantities and units for these drugs against the new limits before submitting claims for dates of service on or after the effective date.
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What to do
Action · 3 steps
01Effective 2026-12-01: Billing team should update charge entry and claim edit checks for Exdensur (depemokimab), Spinraza (nusinersen), J2326, J2361, Q5136 and Q5157 so that units billed per administration and frequency match the revised maximum allowed quantities for New Mexico Medicaid members.
02Providers and front desk staff should be told that services exceeding the stated maximum dosage or frequency will be considered not medically necessary and may be denied, so scheduling and dosing documentation should reflect the limits.
03Where a patient's body weight exceeds 140 kg or body surface area exceeds 2.71 m2, document the patient's measurements in the chart so claims for higher units can be supported on appeal or resubmission.
Codes mentioned
J2326J2361Q5136Q5157
Original notice
Maximum Dosage and Frequency
uhcprovider.com · Always check the source before changing claims.
Related changes
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