CurrentEmblemHealthPolicy MGMM.PH.329

Aduhelm (aducanumab-avwa) coverage

This policy governs EmblemHealth coverage determinations for Aduhelm (aducanumab-avwa) for applicable members and outlines required documentation for review. It affects treating physicians and providers submitting preauthorization or post-payment review requests to EmblemHealth/ConnectiCare.

Policy Summary

PayerEmblemHealth

PolicyAduhelm (aducanumab-avwa) coverage

Policy CodePolicy MGMM.PH.329

Change TypeNo material change

Effective Date

Next Review DateApr 29, 2024

Key ActionSubmit clinical evidence that the member meets criteria for preauthorization or post-payment review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredcoverage stance for Aduhelm

J0172procedure code

64406-101-01; 64406-102-02NDCs

Apr 29, 2024last review

Coverage Determination and Criteria

Primary Coverage Determination

Policy Summary

PayerEmblemHealth

PolicyAduhelm (aducanumab-avwa) coverage

Policy CodePolicy MGMM.PH.329

Change TypeNo material change

Effective Date

Next Review DateApr 29, 2024

Key ActionSubmit clinical evidence that the member meets criteria for preauthorization or post-payment review.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization, Documentation, and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Aduhelm (aducanumab-avwa). EmblemHealth will not cover Aduhelm due to lack of conclusive evidence confirming clinical efficacy. Providers must obtain preauthorization before initiating treatment; failure to do so may result in denial of the request or non-payment.

Preauthorization required — submit prior authorization request to EmblemHealth (or ConnectiCare as applicable) before providing Aduhelm.
EmblemHealth non-coverage stance — Aduhelm is not covered under this policy due to insufficient evidence of clinical benefit; Medicare members should refer to separate LCD/NCD Medicare criteria.

Documentation Required

Submission of Clinical Evidence

The treating physician or primary care provider must submit clinical evidence demonstrating that the member meets the stated criteria for the requested treatment. Documentation must be provided to EmblemHealth (or ConnectiCare, as applicable) to allow clinical review of medical necessity.

Detailed clinical notes summarizing diagnosis, symptom history, and functional impact.
Relevant diagnostic testing and results (e.g., cognitive testing scores, imaging, biomarkers) where applicable.
Treatment history, including prior therapies and responses, and rationale for Aduhelm.
Provider contact information and specialty credentials to support the request.

Denial Risk

Documentation Required for Review

Failure to submit the required clinical evidence will prevent EmblemHealth from performing a proper review and may lead to denial of preauthorization or post-payment review. Providers should include complete and legible documentation at the time of submission to avoid delays or adverse determinations.

Incomplete or missing documentation may result in denial of the request or request for additional information.
Keep copies of all submitted records; respond promptly to medical record requests from EmblemHealth.
For Medicare members, ensure any additional Medicare-specific documentation per LCD/NCD is provided when applicable.

Background

Aduhelm (aducanumab‑avwa) is an amyloid beta‑directed monoclonal antibody indicated for Alzheimer’s disease that received approval through the FDA Accelerated Approval pathway. The approval was based on reduction of amyloid beta plaque as a surrogate endpoint rather than demonstrated clinical benefit; post‑approval trials are required to verify clinical efficacy and the reduction in plaque has not been proven to provide clinical benefit.

Definitions

inv-11: Aduhelm (aducanumab-avwa) — summary

Drug name (generic/brand)aducanumab-avwa (Aduhelm)

MechanismAmyloid beta‑directed monoclonal antibody (targets and reduces amyloid beta plaque)

IndicationTreatment of Alzheimer's disease

Regulatory/approval pathwayFDA Accelerated Approval Pathway (approval based on surrogate endpoint: reduction of amyloid beta plaque)

Clinical benefit statusReduction in amyloid beta plaque is not proven to provide clinical benefit; post‑approval trials required to verify benefit — FDA may withdraw approval if benefit not verified

EmblemHealth coverage stanceNot covered due to lack of conclusive evidence confirming clinical efficacy

G30.0	Alzheimer's disease with early onset
G30.1	Alzheimer's disease with late onset
G30.9	Alzheimer's disease, unspecified
G31.84	Mild cognitive impairment, so stated

OpenPayer

Aduhelm (aducanumab-avwa) coverage

Coverage Determination and Criteria

Billing Codes and Identifiers

Authorization, Documentation, and Submission Requirements

Background

Definitions

64406-101-01	170 mg/1.7 mL (100 mg/mL) single-dose vial
64406-102-02	300 mg/3 mL (100 mg/mL) single-dose vial