Medicare AdvantagePrior AuthMedium impact
MA08.052n, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
Independence Blue Cross·Endocrinology, Oncology, Rheumatology +1 more·Pharmacy
Effective date
Feb 24, 2025
We identified it
Jun 19, 2026
Summary
Policy MA08.052n updates medical necessity criteria for Denosumab (Prolia®, Xgeva®), biosimilars, and Romosozumab-aqqg (Evenity®) effective February 24, 2025. This is a recent pharmacy policy change that may affect prior authorization requirements, coverage determinations, and billing workflows for these osteoporosis and bone metastasis medications.
Action Required
By February 24, 2025: Billing and clinical teams must review the full policy text at the provided URL to identify specific medical necessity criteria changes for Denosumab products (Prolia®, Xgeva®) and Romosozumab-aqqg (Evenity®). Update prior authorization protocols, claim submission guidelines, and provider documentation templates in the billing system to reflect new criteria. Communicate changes to prescribing providers and prior authorization staff. Failure to comply with updated medical necessity criteria will result in claim denials for non-compliant submissions. NOTE: Specific billing codes and detailed requirements are not provided in the policy summary—access the full policy document to implement complete workflow changes.