08.00.12h, Fam-trastuzumab deruxtecan-nxki (Enhertu®)

By June 16, 2025: Billing and prior authorization teams must review the full policy text at the provided URL to identify specific medical necessity criteria for Enhertu® claims. Update prior authorization protocols and supporting documentation requirements in the billing system. Ensure providers submitting claims for this drug include all required clinical documentation per the new criteria. Contact the payer or access the full policy to determine if prior authorization is required and what clinical indicators must be documented. Claims submitted without proper documentation per updated criteria may be denied.