CurrentUnitedHealthcarePolicy CSOH2025D0062.D

Edaravone (for Ohio Only)

Defines UnitedHealthcare Community Plan coverage and medical necessity reference for edaravone for members in Ohio; applies to medical benefit (infusion/injection) requests and directs use of InterQual criteria and Ohio Administrative Code when evaluating requests.

Policy Summary

PayerUnitedHealthcare

PolicyEdaravone (for Ohio Only)

Policy CodePolicy CSOH2025D0062.D

Change TypeTitle and branding updatedcoverage rationale clarified

Effective DateJun 1, 2025

Next Review Date

Key ActionRequest prior authorization using the current InterQual Edaravone guideline and include HCPCS J1301 and diagnosis G12.21 as applicable.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Radicava (Edaravone)' to 'Edaravone' and references to the brand name were replaced with the generic.

1HCPCS code listed

1Diagnosis code listed (ALS)

Ohio-onlyState applicability

InterQualClinical criteria source referenced

Coverage Criteria for Edaravone

Policy Summary

PayerUnitedHealthcare

PolicyEdaravone (for Ohio Only)

Policy CodePolicy CSOH2025D0062.D

Change TypeTitle and branding updatedcoverage rationale clarified

Effective DateJun 1, 2025

Next Review Date

Key ActionRequest prior authorization using the current InterQual Edaravone guideline and include HCPCS J1301 and diagnosis G12.21 as applicable.

SourceLink

On This Page

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Coverage Rationale (per InterQual)

Covered when medical necessity is met per InterQual guideline

InterQual-based coverage: Coverage is provided for edaravone when the current InterQual®reg guideline for Edaravone (Radicava, Radicava ORS) criteria are satisfied

Providers must reference the InterQual guideline for specific inclusion/exclusion and continuation criteria

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for edaravone per InterQual criteria and Ohio rules. Requests for services that are stated as unproven, or services subject to coverage or quantity limits, will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01 and the current InterQual guideline for Edaravone (Radicava, Radicava ORS). Refer to the InterQual guideline for any step therapy or sequencing requirements.

Prior authorization required per InterQual and Ohio rules
Refer to the InterQual guideline for step therapy or sequencing requirements
Requests for services stated as unproven will be evaluated using Ohio Administrative Code 5160-1-01 and InterQual

Billing Rule

Billing / Coding Reference

HCPCS code and diagnosis information provided for billing reference. Inclusion of a code does not guarantee coverage or payment; verify benefit plan, state, and contractual requirements prior to billing.

HCPCS: J1301 — Injection, edaravone, 1 mg
Diagnosis (for reference): G12.21 — Amyotrophic lateral sclerosis

Background

Edaravone is used in the treatment of amyotrophic lateral sclerosis (ALS). Detailed medical necessity determinations for edaravone are delegated to the current InterQual Specialty Rx Non‑Oncology guideline for Edaravone (Radicava, Radicava ORS); providers must follow that InterQual guideline to assess initial eligibility, continuation criteria, and any sequencing or step‑therapy requirements. Requests should be submitted with documentation per InterQual and applicable Ohio requirements.

Initial Therapy Criteria

Initial Therapy — contingent on InterQual inclusion criteria

Initial coverage contingent on InterQual inclusion criteria

Initial therapy per InterQual: Initial authorization requires meeting the current InterQual initial therapy criteria for Edaravone

Providers should supply documentation required by InterQual and Ohio Administrative Code 5160-1-01

Step	Requirement / Notes
1	Any step therapy or sequencing requirements for edaravone are specified in the current InterQual® guideline for Edaravone (Radicava, Radicava ORS); follow InterQual sequencing when applicable.

Site of Care Considerations

Note

Infusion center — medical benefit drug; site-of-care decisions follow benefit plan, InterQual, and Ohio regulations

This is a medical benefit drug administered in an infusion center; site-of-care determinations must follow the member’s benefit plan, applicable InterQual guidance, and Ohio regulations.

Infusion center administration is under the medical benefit.
Follow benefit plan terms, InterQual criteria, and Ohio Administrative Code when determining site of care.

OpenPayer

Edaravone (for Ohio Only)

Coverage Criteria for Edaravone

Relevant Coding

Provider Actions and Authorization Requirements

Background

Definitions

Initial Therapy Criteria

Continuation Therapy Criteria

Step Therapy / Sequencing

Site of Care Considerations