CurrentUnitedHealthcarePolicy MMP057.50

Medications/Drugs (Outpatient/Part B)

Defines Medicare Part B and Part D coverage distinctions, specific Part B-covered medication categories (e.g., DME supply drugs, nebulizer drugs, infusion pump medications, immunosuppressive drugs, IVIG, oral anti-cancer/anti-emetic rules), exclusions (e.g., investigational drugs, placebos, outpatient prescription drugs, sexual/erectile dysfunction, elective enhancement), program controls (RAL, step therapy, maximum dosage/frequency) and references to NCDs/LCDs and related UnitedHealthcare policies.

Policy Summary

PayerUnitedHealthcare

PolicyMedications/Drugs (Outpatient/Part B)

Policy CodePolicy MMP057.50

Change TypeAdded guidance (RAL); document updates; archival

Effective DateMarch 1, 2026

Next Review Date

Key ActionProviders are strongly encouraged to request a pre-service organization determination for RAL medications to avoid coverage gaps.

POLICY UPDATE CHANGES

Added coverage guidelines for Boncresa (denosumab-mobz), Nufymco (ranibizumab-leyk), and Yartemlea (narsoplimab-wuug).

Updated list of documents available in the Medicare Coverage Database to reflect the most current information.

Archived previous policy version MMP057.49.

multipleCovered Indications/Categories described

severalNot Covered Categories described

RAL/Step/MaxDoseUtilization Management mechanisms referenced

Medications listed in this section

3Newly Added Drug Guidelines

1Policy version archived

Coverage Summary

This UnitedHealthcare Medicare Advantage policy interprets Medicare Part B and Part D coverage distinctions for outpatient medications. Part B covers drugs furnished 'incident' to a physician's service that are Not Usually Self-Administered By the Patient and is usually limited to injectable/infusion drugs, with exceptions where specific rules apply; Part D covers prescription drugs when Part A/B payment could not be made. Key Part B-covered categories addressed include: DME supply drugs that must be put directly into durable medical equipment, nebulizer inhalation drugs used in the home (not MDI delivery), infusion pump medications administered via implantable or, where applicable, external pumps, immunosuppressive drugs after a Medicare-covered organ transplant, intravenous immune globulin (IVIG) in the home for primary immune deficiency and for specified biopsy-proven autoimmune mucocutaneous blistering diseases, and specific rules for oral oncology and oral anti-emetic drugs (Part B billed when used for cancer treatment or used as a full replacement for IV anti-emetic within 48 hours and so documented). The policy also lists examples of drugs treated as hospital outpatient supplies (packaged) and drugs not covered under Part B.

Exclusions and not-covered categories are explicit and include investigational/experimental drugs, placebos, many outpatient prescription drugs (those covered by Part D), medications for sexual/erectile dysfunction and elective enhancement, and drugs on the CMS Self-Administered Drug Exclusion List. The policy references Medicare manuals, NCDs, LCDs/LCAs and UnitedHealthcare commercial drug policies as governing sources and notes program controls such as Review at Launch (RAL), Step Therapy, and Maximum Dosage and Frequency that may apply to listed medications.

Policy metadata and review dates

policy_numberMMP057.50

dates.effectiveMarch 1, 2026

dates.last_reviewFebruary 11, 2026

dates.next_review

statusCURRENT

scope_summaryDefines Medicare Part B and Part D coverage distinctions, specific Part B-covered medication categories (e.g., DME supply drugs, nebulizer drugs, infusion pump medications, immunosuppressive drugs, IVIG, oral anti-cancer/anti-emetic rules), exclusions, and utilization management (RAL, step therapy, maximum dosage/frequency) with references to NCDs/LCDs and UnitedHealthcare policies.

Medical Necessity Criteria (Part B Coverage Rules)

General Part B Coverage Criteria

Outpatient (Part B) medications/drugs are covered when furnished 'incident' to a physician's service for drugs that are 'Not Usually Self-Administered By the Patient.' Coverage usually limited to injectable/infusion drugs unless specific exceptions apply.

ALL of the following

Drug is furnished 'incident' to a physician's service
Drug is 'Not Usually Self-Administered By the Patient' as defined by Medicare (i.e., usually >50% of Medicare beneficiaries do not self-administer)

DME Supply Drugs (Part B)

Drugs/biologicals necessary for effective use of durable medical equipment and must be put directly into equipment.

ALL of the following

Not Covered and Experimental Uses

Not Covered Medications/Drugs (Summary)

Summary of Not Covered categories (accessible from Not Covered section): Vitamin B12 foot injections; investigational/experimental drugs; placebos; outpatient prescription drugs (Part D); sexual/erectile dysfunction for that purpose; elective enhancement drugs; CMS Self-Administered Drug Exclusion List items.

Off-label or unlabeled use of a Part B drug is not covered unless a UnitedHealthcare Medical Director or designee determines the use is medically accepted. That determination must consider major drug compendia, authoritative medical literature, and accepted standards of medical practice (per Medicare Benefit Policy Manual Chapter 15 guidance). For oncology-related off-label uses, the policy references compendia and specific UnitedHealthcare oncology policies when NCCN Category indications apply. Investigational/experimental drugs and placebos are explicitly listed as not covered in the Not Covered section.

Coding and Medicare/NCD/LCD References

Referenced NCDs / Medicare Manuals / LCDsmixed

NCD 250.3	Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases
NCD 110.18	Aprepitant for Chemotherapy-Induced Emesis
NCD 150.6	Vitamin B12 Injections to Strengthen Tendons, Ligaments, etc., of the Foot

Examples of medications listed in Supporting Informationmixed

Adakveo (crizanlizumab-tmca)	Other Examples of Specific Drugs/Medications; defaults and RAL/step therapy/maximum dosage flags indicated
Adzynma (ADAMTS13, recombinant-krhn)	Other Examples of Specific Drugs/Medications; default policy mapping to UnitedHealthcare Commercial policy
Akynzeo (netupitant and palonosetron) injection	Antiemetic injectable listed in supporting information
Aloxi (palonosetron hydrochloride) injection	Antiemetic injectable listed
Cinvanti (aprepitant) injectable emulsion	Antiemetic injectable listed
Emend (fosaprepitant) injection	Antiemetic injectable listed
Focinvez (fosaprepitant) injection	Antiemetic injectable listed
Kytril (granisetron) injection	Antiemetic injectable listed
Posfrea (palonosetron) inj	Antiemetic injectable listed

Examples with MAC/LCD referencesmixed

L38920	CGS LCD reference for Rituximab non-chemo therapeutic
A58582	Associated local code reference
L38268	LCD reference
A57160	Associated local code reference
L39297	NGS LCD reference
A59101	Associated local code reference
L35026	Palmetto LCD reference
A56380	Associated local code reference
A55639	WPS reference
L33394	NGS LCD (e.g., sodium hyaluronate, Soliris)

1–10 of 33

1/4

Products cross-referenced to UnitedHealthcare commercial medical benefit drug policiesmixed

Orencia	Refer to UnitedHealthcare Commercial Medical Benefit Drug Policy titled Orencia (abatacept)
Oxlumo	Refer to UnitedHealthcare Commercial Medical Benefit Drug Policy titled Oxlumo (lumasiran) and Rivfloza (nedosiran)
Papzimeos	Refer to UnitedHealthcare Commercial Medical Benefit Drug Policy titled Papzimeos
Pemetrexed	Refer to Oncology Medication Clinical Coverage policy
PiaSky	Refer to Complement Inhibitors policy
Primacor	DME MAC LCD for External Infusion Pumps applicable
Qalsody	Refer to UnitedHealthcare Commercial Medical Benefit Drug Policy titled Qalsody (Tofersen)
Qivigy	Refer to UnitedHealthcare Commercial Medical Benefit Drug Policy titled Immune Globulin (IVIG and SCIG)
Radicava	Refer to UnitedHealthcare Commercial Medical Benefit Drug Policy titled Edaravone
Reblozyl	Refer to UnitedHealthcare Commercial Medical Benefit Drug Policy titled Reblozyl

1–10 of 36

1/4

CMS/Medicare LCDs, LCAs and contractor references listedmixed

L35891	Intravenous Immune Globulin (IVIG) - LCD
L34007	Immune Globulin - LCD
L39314	Off-Label Use of Intravenous Immune Globulin (IVIG) - LCD
L34074	Immune Globulin Intravenous (IVIg) - LCD
L35093	Immune Globulin - LCD
L33610	Intravenous Immune Globulin - LCD
L34580	Intravenous Immunoglobulin (IVIG) - LCD
L34771	Immune Globulins - LCD

mixed

No codes listed

Providers must follow CMS and CPT coding guidance and submit accurate claims; references to CPT/CMS are for definitional purposes and do not guarantee payment. Where applicable, providers should comply with referenced MACs, NCDs, LCDs and LCAs and the CMS Medicare Coverage Database. The policy directs providers to follow named MAC/LCD/LCA references and the cross-referenced UnitedHealthcare commercial drug policies when no LCD/LCA exists.

Provider Actions and Requirements

Documentation Required

Home administration documentation for IVIG and DME drugs

Home infusion and durable medical equipment (DME) drugs administered in the home must have documentation demonstrating home administration when required by policy. Maintain contemporaneous records that show the drug was administered in the home setting, the date(s) of service, route of administration, dose, frequency, supervising/ordering physician, and any home health or infusion nursing provider involved. For IVIG and DME-supplied drugs, retain infusion records, medication administration records, and any patient education or competency documentation that supports home administration.

Document home administration: date, route, dose, frequency, supervising physician, administering clinician/provider
Retain infusion records and medication administration records for IVIG and DME drugs
Include any patient education/competency documentation and supplier/supporting notes

Prior Authorization

Background and Definitions

This UnitedHealthcare Medicare Advantage policy interprets Medicare Part B and Part D rules, referencing the Medicare Benefit Policy Manual, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs), and relevant CMS manuals. It provides guidance on categories including DME supply drugs, nebulizer inhalation drugs, infusion pump medications, immunosuppressive drugs, IVIG, and oral oncology/anti-emetic rules, and lists the CMS/MAC documents and contractor references applicable to those categories.

Term	Definition
Not Usually Self-Administered By the Patient
'Administered' refers to the physical process only; 'Usually' means more than 50% of Medicare beneficiaries do not self-administer; 'By the Patient' refers to Medicare beneficiaries as a collective whole.
Homebound
Defined criteria: need for aid of supportive devices/assistance or leaving home medically contraindicated; plus normal inability to leave home and leaving requires considerable/taxing effort; infrequent short absences allowed.
FDA Approved Drug
Drug with final marketing approval from FDA including labeling with recommended uses/dosages and precautions.
Unlabeled Use of Drug
Use not included as an indication on the FDA-approved label.
Review at Launch (RAL)
A pre-service review required for certain newly launched products to assess coverage prior to service delivery.
MAC
Medicare Administrative Contractor — contractor responsible for administering Medicare fee-for-service claims in designated jurisdictions.

Medicare NCDs / LCDs Referenced

Type (NCD/LCD)	Number	Name	Effective Date
{"text":"NCD","status":""},{"text":"250.3","status":""},{"text":"IVIG for Autoimmune Mucocutaneous Blistering Diseases","status":""},{"text":"","status":""}
{"text":"NCD","status":""},{"text":"110.18","status":""},{"text":"Aprepitant for Chemotherapy-Induced Emesis","status":""},{"text":"","status":""}
{"text":"NCD","status":""},{"text":"150.6","status":""},{"text":"Vitamin B12 Injections to Strengthen Tendons, Ligaments, etc., of the Foot","status":""},{"text":"","status":""}
{"text":"NCD","status":""},{"text":"110.21","status":""},{"text":"Erythropoiesis Stimulating Agents in Cancer and Related Neoplastic Conditions","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"L33394 (A52370)","status":""},{"text":"Bevacizumab (NGS)","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"L33394 (A52370)","status":""},{"text":"Bevacizumab related (NGS)","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"L33394 (A52399) (A52855)","status":""},{"text":"Denosumab related (NGS)","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"L33394 (A54548)","status":""},{"text":"Eculizumab related (NGS)","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"L37176 (A56748) (A54682)","status":""},{"text":"Colony Stimulating Factors (Palmetto)","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"CGS L33949 (A56472); First Coast L33274 (A57715); NGS L33646 (A52848); Noridian L35170 (A57185); L35172 (A57186); Novitas L38809 (A58423); Palmetto L33458 (A56646); WPS L34635 (A57474)","status":""},{"text":"Botulinum toxin (CGS/First Coast/NGS/Novitas/Palmetto/WPS)","status":""},{"text":"","status":""}
{"text":"NCD","status":""},{"text":"200.3","status":""},{"text":"NCD for Monoclonal Antibodies Directed Against Amyloid","status":""},{"text":"","status":""}
{"text":"NCD","status":""},{"text":"110.10","status":""},{"text":"NCD for Intravenous Iron Therapy","status":""},{"text":"","status":""}
{"text":"NCD","status":""},{"text":"110.17","status":""},{"text":"NCD for Anti-Cancer Chemotherapy for Colorectal Cancer","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"","status":""},{"text":"DME MAC LCD for External Infusion Pumps","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"A58578/A58579","status":""},{"text":"Noridian A58578/A58579 (Spinraza references)","status":""},{"text":"","status":""}
{"text":"LCD","status":""},{"text":"multiple (see code group entries)","status":""},{"text":"Intravenous Immune Globulin (IVIG)","status":""},{"text":"","status":""}

Revision History

03/01/2026addedLatest

Added coverage guidelines for Boncresa (denosumab-mobz); Review at Launch (RAL) required.

03/01/2026addedLatest

Added coverage guidelines for Nufymco (ranibizumab-leyk); Review at Launch (RAL) required.

03/01/2026added

Policy Summary

PayerUnitedHealthcare

PolicyMedications/Drugs (Outpatient/Part B)

Policy CodePolicy MMP057.50

Change TypeAdded guidance (RAL); document updates; archival

Effective DateMarch 1, 2026

Next Review Date

Key ActionProviders are strongly encouraged to request a pre-service organization determination for RAL medications to avoid coverage gaps.

On This Page

Drug/biological is necessary for effective use of DME or assures proper functioning of equipment

Furnished for use in the patient's home (not hospital/SNF/other listed facilities)

Nebulizer Inhalation Drugs (Part B)

Covered when used with a nebulizer in the home; not covered if delivered by metered dose inhaler.

ALL of the following

Drug is an inhalation drug used with a nebulizer
Drug is furnished for use in the patient's home (not hospital/SNF/other listed facilities)

Infusion Pump Medications (Part B)

Generally billed to Part B when administered using an infusion pump (implantable or, if included under local coverage, external pump).

ANY of the following

Drug is administered using an implantable infusion pump
Drug is infused in the home using an external pump and included under local coverage policy of the applicable Medicare DME MAC

Not furnished in hospital or SNF when that facility is the patient's current location (then Part D would apply)

Immunosuppressive Drugs (Post-Transplant)

Covered following a Medicare covered organ transplant when FDA-labeled or determined by DME MAC to be reasonable and necessary.

ANY of the following

Drug has FDA approval with labeling indication for preventing/treating transplant rejection
Drug has FDA approval with labeling for use in conjunction with immunosuppressive drugs to prevent/treat rejection
Drug approved by FDA and determined by DME MAC to be reasonable and necessary for preventing/treating rejection
Compounded formulation derived only from a drug described above and orally or enterally administered

Coverage irrespective of self-administration. Non-rejection-related drugs (e.g., antibiotics, hypertensives) are not covered under this benefit.

IVIG in the Home (Primary Immune Deficiency)

IVIG covered in the home under Part B if ALL criteria are met:

ALL of the following

IVIG is an approved pooled plasma derivative for primary immune deficiency disease
Patient has a diagnosis of primary immune deficiency disease (refer to Medicare Benefit Policy Manual Chapter 15 and applicable LCDs/LCAs)
IVIG is administered in the home
Treating physician determines that home administration is medically appropriate

IVIG for Autoimmune Mucocutaneous Blistering Diseases

IVIG is covered for biopsy-proven diagnoses:

ANY of the following

Pemphigus vulgaris
Pemphigus foliaceus
Bullous pemphigoid
Mucous membrane pemphigoid (cicatricial pemphigoid)
Epidermolysis bullosa acquisita

Injectable Drugs for Osteoporosis (Home Health Agency)

Covered when ALL criteria are met:

ALL of the following

Member unable to learn skills to self-administer OR physically/mentally incapable AND family/caregiver unable or unwilling to administer (documented by home health agency)
Member sustained a bone fracture certified as related to post-menopausal osteoporosis by physician/allowed practitioner/certified nurse midwife
Member is Homebound

Drugs Treated as Hospital Outpatient Supplies (Part B)

Drugs considered integral to a procedure may be packaged as supplies and billed under Part B as hospital supplies.

ANY of the following

Sedatives administered in preoperative area for procedure
Mydriatic/anti-inflammatory/antibiotic/ocular hypotensive drops administered immediately before/during/after ophthalmic procedure
Barium or low osmolar contrast media integral to diagnostic imaging procedure
Topical solution used with photodynamic therapy for non-hyperkeratotic actinic keratosis lesions at hospital
Antibiotic ointments placed on wound/surgical incision at procedure completion

Examples not packaged (i.e., not supplies)

Drugs given for continued use at home after leaving hospital
Oral pain medication for outpatient with headache during chemotherapy
Routine insulin or hypertension medication given preoperatively
Fentanyl patch or oral pain medication to outpatient presenting with pain
Laxative suppository while waiting for unrelated X-ray

Oral Anti-Cancer and Oral Anti-Emetic Drugs

Coverage depends on indication and relationship to IV therapy and cancer treatment timing.

ANY of the following

Oral anti-cancer drugs: Part B billed if used for cancer treatment; otherwise Part D
Oral anti-emetics: Part B billed if used as a full replacement for IV anti-emetic within 48 hours of cancer treatment and physician indicates this on the prescription; otherwise Part D

Not Covered Medications/Drugs

Examples of categories not covered under Part B unless other criteria apply:

ANY of the following

Vitamin B12 injections to strengthen foot tendons/ligaments (NCD 150.6)
Investigational/experimental drugs
Placebos
Outpatient prescription drugs (except those covered under member's Part D plan)
Medications for sexual or erectile dysfunction when prescribed for sexual/erectile dysfunction
Medications for elective enhancement (weight loss, hair growth, cosmetic, anti-aging, mental performance, athletic performance)
Drugs included in CMS Self-Administered Drug Exclusion List

Off-Label/Unlabeled Drug Use

Not covered unless a UnitedHealthcare Medical Director or designee determines the use to be medically accepted considering compendia and literature.

Medical Director/designee determination of medically accepted off-label use based on compendia, authoritative medical literature, and accepted standards of practice

Review at Launch (RAL) Medications

Pre-service organization determination recommended for new-to-market Part B medications without established utilization management strategy.

Medication is new to market

Medication has not undergone review by UnitedHealthcare

No utilization management strategy has been established

Upon pre-service determination, review will reference NCDs/LCDs, and in absence, UnitedHealthcare policy or FDA labeling, compendia, and evidence-based literature

Step Therapy Program

Applies to certain Medicare Part B medical injectables listed in the Other Examples table; non-preferred therapies generally require history of use of preferred therapy.

Medication is listed in the Other Examples of Specific Drugs/Medications table with a Step Therapy notation

Step therapy requirement applies to some, but not all, Medicare Advantage Plans

Maximum Dosage and Frequency

Certain medications have maximum dosage per administration and dosing frequency; applicable when noted in Other Examples table or LCD/LCA.

Medication is listed in Other Examples table with Maximum Dosage and Frequency notation or subject to LCD/LCA maximums

Any LCD/LCA maximum dosage and frequency criteria would be applicable, if available.

Pre-service organization determination for RAL medications

Pre-service review and organization determination (Review at Launch, RAL) is required for certain rapidly launching (RAL) injectable medications. This pre-service determination requirement applies to select RAL-designated products and must be completed prior to claim submission. Specifically, RAL processing applies to Boncresa, Nufymco, and Yartemlea as noted in the policy updates. Providers should initiate a pre-service organization determination for these agents to confirm coverage criteria, applicable step therapy, and any prior authorization requirements.

Pre-service organization determination (Review at Launch, RAL) required for some drugs
Applies to RAL drugs including Boncresa, Nufymco, and Yartemlea
Complete pre-service review prior to claim submission to confirm coverage and prior authorization

Step Therapy

Step therapy for selected Part B injectables

Step therapy requirements apply to selected Part B injectable drugs where specified by UnitedHealthcare and/or Medicare guidance. When step therapy is indicated, members must meet the defined prior treatment steps before coverage of the requested agent is approved. For Medicare members, follow and refer to the Medicare Part B Step Therapy programs and any cross-referenced step therapy policies. Providers should confirm member-specific step therapy requirements during pre-service review.

Step therapy applies to some Medicare Part B drugs; verify applicability during pre-service review
Refer to UnitedHealthcare and Medicare Part B Step Therapy program details and cross-referenced drug-specific step therapy policies
Document prior treatments and clinical rationale when requesting an exception

Billing Rule

Hospital packaged supplies billing guidance

Billing for hospital-packaged supplies and DME-associated drugs must follow CMS and UnitedHealthcare billing guidance. When supplies are hospital packaged, do not separately bill for items included in the hospital package. Follow Medicare/CPT/CMS coding guidelines and MAC/LCD/LCA instructions for appropriate HCPCS/CPT usage and modifier application. Ensure documentation supports separate billing only when supplies are not included in the packaged rate.

Do not separately bill for hospital-packaged supplies included in the facility’s bundled payment
Follow Medicare/CPT/CMS coding guidelines and MAC/LCD/LCA instructions for HCPCS/CPT coding and modifiers
Ensure documentation justifies separate billing when supplies are not packaged

Documentation Required

Orem anti-emetic prescription annotation

When oral anti-emetics are used as IV substitution within 48 hours, the physician must annotate the chart to indicate that an oral anti-emetic was used as an IV replacement and the clinical rationale for IV administration. Preserve the original typo from source: providers should follow the 'Orem' annotation instruction as noted. Documentation should include date/time, drug name, dose, route change, and clinical justification.

Physician annotation required when oral anti-emetics are used as IV replacements within 48 hours
Include date/time, drug name, dose, route change, and clinical justification
Preserve documentation (per source: 'Orem anti-emetic prescription annotation')

Documentation Required

Follow applicable LCDs/LCAs when present

Follow applicable Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) when present; where an LCD/LCA exists it takes precedence for Medicare claims. If no LCD/LCA applies, refer to the default UnitedHealthcare drug policy and any cross-referenced drug-specific policies. Confirm and apply MAC/LCD/LCA guidance, UnitedHealthcare default policy, and any product-specific coverage criteria.

Follow applicable MAC/LCD/LCA when present; LCD/LCA guidance governs Medicare claims
If no LCD/LCA exists, refer to the default UnitedHealthcare drug policy and cross-referenced drug-specific policies
Confirm applicability of MAC/LCD/LCA and UnitedHealthcare Default Policy during pre-service review

Prior Authorization

Step therapy reference when indicated

When step therapy is indicated by policy or Medicare guidance, follow the referenced step therapy program and related cross-references. Providers must document prior step(s) tried and failed, or provide clinical justification for exception requests. See linked drug-specific policies and the Medicare Part B Step Therapy programs for details.

Refer to step therapy program when indicated and to drug-specific step therapy cross-references
Document prior therapies and clinical rationale for exceptions
Step therapy applicability must be confirmed at pre-service determination

Billing Rule

Maximum dosage/frequency references

Maximum dosage and frequency limits referenced in drug-specific UnitedHealthcare policies, LCDs/LCAs, and manufacturer labeling must be observed. Billing that exceeds published maximums may be subject to denial. Verify units, frequency, and dosing thresholds against the applicable policy and document clinical justification when exceeding standard limits.

Follow maximum dosage/frequency references in drug-specific policies, LCDs/LCAs, and FDA labeling
Claims exceeding published maximums may be denied without supporting clinical justification
Document justification when requesting doses/frequencies above policy thresholds

Documentation Required

Refer to MAC/LCD/LCA and Default Policy

Refer to the applicable Medicare Administrative Contractor (MAC) LCD/LCA and the UnitedHealthcare Default Drug Policy for guidance when determining coverage. Cross-reference drug-specific UnitedHealthcare policies for additional clinical and coverage details. Use the MAC/LCD/LCA as the primary Medicare reference and the Default Policy when no local coverage guidance exists.

Refer to MAC/LCD/LCA first for Medicare claims; use UnitedHealthcare Default Policy when no LCD/LCA applies
Cross-reference drug-specific UnitedHealthcare policies for clinical criteria
Confirm coverage basis during pre-service review

Documentation Required

Maintain supporting documentation

Maintain supporting clinical documentation to demonstrate medical necessity and compliance with coverage criteria. Documentation should include diagnosis, relevant labs/imaging, prior therapies and responses, rationale for selected agent, dosing and frequency, treatment dates, and physician orders. Proper documentation supports pre-service determinations, appeals, and claims processing.

Retain clinical notes, labs/imaging, prior therapy history, and physician orders to support medical necessity
Documentation is required for pre-service reviews (including RAL), step therapy exceptions, and claims audits
Follow Medicare/CPT/CMS coding and documentation guidelines

Added coverage guidelines for Yartemlea (narsoplimab-wuug); Review at Launch (RAL) required.

03/01/2026added_materialLatest

Added coverage guidelines for Boncresa, Nufymco, and Yartemlea; language added to indicate a pre-service review (Review at Launch, RAL) is required for these products. (This change is material.)

03/01/2026updated

Updated list of Centers for Medicare and Medicaid Services (CMS) related documents and Medicare Coverage Database references to reflect the most current information.

03/01/2026archived

Archived previous policy version MMP057.49.