Summary
Effective 2027-01-01, UnitedHealthcare Community Plan of Tennessee revised its Medicaid medical benefit policy for denosumab. Jubereq and Osvyrti are now preferred products covered under the Diagnosis-Specific Criteria, while Boncresa, Oziltus, and Ponlimsi are non-preferred products covered only if the Preferred Product Criteria and Diagnosis-Specific Criteria are both met. The policy also adds a very-high-fracture-risk criterion for initial osteoporosis therapy and adds HCPCS codes Q5166, Q5171, and Q5173.
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What to do
Action · 5 steps
01By 2027-01-01: Billing team and providers should review denosumab orders for Tennessee Community Plan Medicaid members and confirm whether each requested product is preferred (Jubereq, Osvyrti) or non-preferred (Boncresa, Oziltus, Ponlimsi).
02For non-preferred products, document that the Preferred Product Criteria are met before the claim is submitted.
03For all denosumab products, document the Diagnosis-Specific Criteria, including the very-high-fracture-risk indicators (recent fracture in the past 12 months, fracture on approved osteoporosis therapy, multiple fractures, fracture on drugs causing skeletal harm, BMD T-score below -3.0, high fall risk or injurious fall history, or FRAX thresholds), in the chart and prior authorization request.
04Update the charge master and claim entry so the new HCPCS codes Q5166, Q5171, and Q5173 are available for the correct products, and tell providers and front desk staff about the product preference change.
05Claims for non-preferred products that do not meet the criteria will be denied.
Codes mentioned
Q5166Q5171Q5173
Original notice
Denosumab
uhcprovider.com · Always check the source before changing claims.
Related changes
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