Medicare AdvantageDocumentationMedium impact
MA08.104c, Emapalumab-lzsg (Gamifant®)
Independence Blue Cross·MA · Hematology, Oncology, Pharmacy +1 more·Pharmacy
Effective date
Jul 28, 2025
We identified it
Jun 19, 2026
Summary
Policy MA08.104c updates medical necessity criteria and medical coding guidance for Emapalumab-lzsg (Gamifant®), a drug used to treat hemophagocytic lymphohistiocytosis (HLH). This recent policy change affects how claims for this specialty pharmaceutical are coded and justified under Medicare Advantage plans. Billing teams must review updated medical necessity requirements and ensure claims comply with new coding standards to avoid denials.
Action Required
By August 28, 2025 (30 days from effective date): Billing and clinical teams must review the full policy text at the provided URL to identify specific medical necessity criteria and coding requirements for Emapalumab-lzsg (Gamifant®) claims. Update billing system rules, prior authorization templates, and clinical documentation requirements to reflect new medical necessity standards. Notify providers prescribing Gamifant® of documentation expectations. Monitor claims for denials and adjust processes as needed. Without compliance, claims may be denied for failure to meet updated medical necessity criteria.