Summary
UnitedHealthcare Community Plan of Tennessee revised its FcRn Blockers medical benefit drug policy, with a stated effective date of 2027-01-01. Imaavy (nipocalimab-aahu) is now covered as proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in adults and children 12 and older who are currently or were previously treated with corticosteroids, subject to documentation, prescriber, dosing and combination-therapy criteria; ICD-10 code D59.11 was added to the policy's applicable codes.
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What to do
Action · 4 steps
01By 2027-01-01: Billing team and providers should confirm that claims for Imaavy for wAIHA are submitted with ICD-10 D59.11 and that the medical records supporting diagnosis (positive DAT or negative DAT with other hemolysis causes excluded, signs and symptoms, corticosteroid or immunosuppressant treatment status, and rituximab trial or contraindication) are in the chart before the drug is scheduled.
02Update charge entry and diagnosis linkage for Imaavy to use D59.11, and have clinical staff document hematologist prescribing or consultation, FDA-labeled dosing, and the requested authorization period (initial no more than 12 months).
03For continuation requests, document positive clinical response to Imaavy and confirm the patient is not receiving rituximab or immune globulin for the same indication.
04Tell providers and front desk staff about these criteria so the prior authorization request is prepared before scheduling.
Codes mentioned
D59.11
Original notice
FcRn Blockers
uhcprovider.com · Always check the source before changing claims.
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