Summary
Medicaid members in Pennsylvania under the UnitedHealthcare Community Plan will see revised FcRn blocker coverage criteria effective 2027-01-01. Imaavy (nipocalimab-aahu) is now described as proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in patients 12 years and older who are currently or were previously treated with corticosteroids, subject to documented diagnosis, prior therapy and prescriber requirements. ICD-10 code D59.11 was added to the applicable codes.
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What to do
Action · 3 steps
01By 2027-01-01: Billing team should confirm that claims for Imaavy for wAIHA submitted to UnitedHealthcare Community Plan of Pennsylvania Medicaid members include diagnosis code D59.11 and that the chart supports the initial-therapy or continuation criteria (confirmed diagnosis with hemolytic anemia and positive or excluded DAT, corticosteroid or immunosuppressant treatment history or intolerance, rituximab trial or contraindication, no concurrent rituximab or immune globulin, FDA-labeled dosing, and hematologist prescribing or consultation).
02Update charge entry and diagnosis lists for these encounters in the practice management system, and obtain prior authorization with medical records before administering Imaavy, as claims without the required authorization and documentation will be denied.
03Providers and infusion staff should be told about the initial authorization limit of 12 months and the 12-month reauthorization period, with reauthorization requests tracked in the prior auth tracker.
Codes mentioned
D59.11
Original notice
FcRn Blockers
uhcprovider.com · Always check the source before changing claims.
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