CommercialDocumentationMedium impact
08.00.94t, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
Independence Blue Cross·Endocrinology, Rheumatology, Oncology +1 more·Pharmacy
Effective date
Feb 24, 2025
We identified it
Jun 19, 2026
Summary
This recent policy (effective 02/24/2025) updates medical necessity criteria for denosumab (Prolia®, Xgeva®), denosumab biosimilars, and romosozumab-aqqg (Evenity®). The billing team must review and implement any new prior authorization requirements, documentation standards, or coverage limitations outlined in the full policy text to ensure compliant claims submission.
Action Required
By 02/24/2025 (effective immediately): Billing team and clinical staff must obtain and review the complete policy text at https://medpolicy.ibx.com/ibc/Commercial/Pages/Site-Activity-View.aspx?FilterField1=MPSiteActivityLogMonth&FilterValue1=02&FilterField2=MPSiteActivityLogYear&FilterValue2=2025#commercial-08-00-94t to identify specific medical necessity criteria changes. Update EMR templates and billing system rules to enforce any new prior authorization triggers, documentation requirements, or eligibility restrictions for claims involving denosumab products (Prolia, Xgeva, biosimilars) and Evenity. Providers should be notified of documentation requirements. Claims submitted without compliance to updated criteria will face denials or rework.