CurrentColorado Rocky Mountain Health PlansPolicy CSOH2025D0023.C

Lemtrada (Alemtuzumab) (for Ohio Only)

This UnitedHealthcare Medical Benefit Drug Policy applies only to Ohio and governs medical necessity determination for Lemtrada (alemtuzumab) using InterQual Specialty Rx Non-Oncology Alemtuzumab criteria. It provides applicable HCPCS coding and references Ohio Administrative Code for evaluation of unproven/limited services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyLemtrada (Alemtuzumab) (for Ohio Only)

Policy CodePolicy CSOH2025D0023.C

Change TypeRoutine reviewno content changes

Effective DateJun 1, 2025

Next Review Date

Key ActionProvider/plan reviewer must apply the current InterQual Specialty Rx Non-Oncology Alemtuzumab guideline to determine medical necessity for Lemtrada requests.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

1HCPCS codes listed

1Reference InterQual guideline

1State-specific (Ohio)

Coverage Summary

This UnitedHealthcare Medical Benefit Drug Policy applies only to Ohio and governs medical necessity determination for Lemtrada (alemtuzumab) using InterQual Specialty Rx Non-Oncology Alemtuzumab criteria. Coverage stance: covered_with_criteria. Effective date: June 1, 2025. Last review date: June 1, 2025.

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Medical Necessity Criteria (per InterQual)

Covered when the InterQual Specialty Rx Non-Oncology Alemtuzumab (Lemtrada) guideline criteria are met:

Request pertains to medication: Request pertains to treatment with Lemtrada (alemtuzumab).
InterQual coverage: Member meets the clinical coverage criteria in the current release of the InterQual guideline for Alemtuzumab (Lemtrada) (CP: Specialty Rx Non-Oncology, Alemtuzumab).
Reviewer must reference the current InterQual guideline linked in the policy.
Ohio-specific rule for unproven/limited services: For services stated as unproven or subject to coverage/quantity limits, medical necessity will be evaluated using Ohio Administrative Code 5160-1-01.
Applicable only for Ohio members; state rules may supersede.

Provider Actions & Documentation

Documentation Required

Use InterQual criteria for medical necessity determination

Provider/plan reviewer must apply the current InterQual Specialty Rx Non-Oncology Alemtuzumab guideline to determine medical necessity for Lemtrada requests.

J0202

Documentation Required

Apply Ohio Administrative Code for unproven/limited services

If services are stated as unproven or have coverage/quantity limits, evaluate medical necessity per Ohio Administrative Code 5160-1-01.

Background & Definitions

Lemtrada (alemtuzumab) coverage is determined using the InterQual clinical criteria (CP: Specialty Rx Non-Oncology, Alemtuzumab). This policy applies only to Ohio. For services stated as unproven or those with coverage or quantity limits, reviewers must evaluate medical necessity using Ohio Administrative Code 5160-1-01.

InterQual: A third-party clinical criteria tool used by UnitedHealthcare to assist in medical necessity determinations (here: Specialty Rx Non-Oncology, Alemtuzumab).