Summary
UnitedHealthcare Community Plan of Tennessee revised its Maximum Dosage and Frequency medical benefit drug policy, updating the maximum allowed HCPCS units and frequencies, adding Exdensur (depemokimab) and Spinraza (nusinersen), adding HCPCS codes J2326 and J2361, and revising the descriptions for Q5136 and Q5157. Billing teams should update claim edits and charge entry so units and dosing frequency for these drugs stay within the new limits, and should verify that services billed beyond the maximum allowed quantities are documented with the clinical rationale the policy requires.
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What to do
Action · 4 steps
01By 2026-12-01: Billing team should review the revised maximum allowed units and frequencies for the listed drugs, including Exdensur (depemokimab) and Spinraza (nusinersen), and update charge entry and claim edits for Tennessee Medicaid UnitedHealthcare Community Plan members so claims reflect the new limits.
02Also update the HCPCS code list in the billing system to add J2326 and J2361 and to use the revised descriptions for Q5136 and Q5157.
03Providers and front desk staff should be told that doses or administration frequencies above the policy maximums will not be supported by labeling or published evidence, so documentation for any exceptions, such as patient weight above 140 kg or body surface area above 2.71 m2, should be attached to the claim or retained in the chart.
04Watch for the payer's next bulletin for any further changes to the maximum allowed quantity list, which the policy notes is subject to change.
Codes mentioned
J2326J2361Q5136Q5157
Original notice
Maximum Dosage and Frequency
uhcprovider.com · Always check the source before changing claims.
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