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MA08.151e, Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease
Act
by Jan 1, 2026
Effective date
Jan 1, 2026
Identified
Jun 19, 2026
Summary
Independence Blue Cross updated MA08.151e to clarify coverage for monoclonal antibodies directed against amyloid (aducanumab, lecanemab, donanemab) for Alzheimer's disease treatment. These drugs remain experimental/investigational and NOT covered except through Medicare's Coverage with Evidence Development (CED) program for patients enrolled in approved clinical studies. Billing teams must ensure claims for these medications are only submitted when patients are actively enrolled in CED clinical trials.
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What to do
by Jan 1, 2026 · 8 steps
01Billing team must implement the following controls.
02Do NOT process claims for HCPCS codes J0172 (aducanumab), J0174 (lecanemab), or J0175 (donanemab) unless the patient is documented as enrolled in a CMS-approved clinical trial under the Coverage with Evidence Development (CED) program.
03Update billing system to require verification of CED clinical trial enrollment before claims submission for these three drugs.
04Add edit/flag in claims processing workflow to deny or hold claims for amyloid-directed monoclonal antibodies without active CED enrollment documentation.
05Train billing staff that these medications are covered ONLY under CED—standard coverage requests will be denied.
06Verify patient CED trial status in medical record before submitting claims.
07Failure to confirm CED enrollment will result in claim denials.
08This applies to all Medicare Advantage members only.
Codes mentioned
J0172J0174J0175G30.0G30.1G30.8G30.9G31.84
Original notice
MA08.151e, Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
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