CurrentUnitedHealthcarePolicy CSOH2025D0048.C

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease (for Ohio Only)

State-specific UnitedHealthcare medical benefit drug policy that governs coverage and medical necessity determination for intravenous enzyme replacement therapies (imiglucerase, taliglucerase, velaglucerase) for members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyIntravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease (for Ohio Only)

Policy CodePolicy CSOH2025D0048.C

Change TypeRoutine reviewno content changes

Effective DateAug 1, 2025

Next Review Date

Key ActionProviders must meet the current InterQual CP clinical coverage criteria for the specific ERT product when requesting coverage; follow UnitedHealthcare prior authorization processes and reference InterQual criteria in submissions.

SourceLink

POLICY UPDATE CHANGES

Routine review performed; no content changes.

3drug products referenced

Ohioapplicability (state-specific)

InterQualexternal clinical criteria referenced

Medically Necessary / Coverage Determination

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.

Medically Necessary / Coverage Determination

Coverage is determined by meeting the current InterQual criteria for Type 1 Gaucher disease for each respective product.

Covered products when InterQual criteria are met

Cerezyme (imiglucerase) — covered when current InterQual CP: Specialty Rx Non‑Oncology, Imiglucerase (Cerezyme) criteria for Type 1 Gaucher disease are met.
Elelyso (taliglucerase alfa) — covered when current InterQual CP: Specialty Rx Non‑Oncology, Taliglucerase alfa (Elelyso) criteria for Type 1 Gaucher disease are met.
VPRIV (velaglucerase alfa) — covered when current InterQual CP: Specialty Rx Non‑Oncology, Velaglucerase alfa (VPRIV) criteria for Type 1 Gaucher disease are met.

Relevant Billing Codes

HCPCS - ImigluceraseHCPCS

J1786

Injection, imiglucerase, 10 units

HCPCS - Taliglucerase alfaHCPCS

J3060

Injection, taliglucerase alfa, 10 units

HCPCS - Velaglucerase alfaHCPCS

J3385

Injection, velaglucerase alfa, 100 units

What Providers Must Do

Documentation Required

Use InterQual clinical criteria

Providers must meet the current InterQual CP clinical coverage criteria for the specific ERT product (imiglucerase, taliglucerase alfa, or velaglucerase alfa) when requesting coverage; InterQual is the clinical standard referenced for medical necessity determinations.

J1786
J3060
J3385

Prior Authorization

Prior authorization requirement implied by policy

Requests for services that are stated as unproven or subject to coverage/quantity limits will be evaluated for medical necessity per Ohio Administrative Code 5160-1-01; providers should follow UnitedHealthcare prior authorization processes and reference InterQual criteria in submissions.

OAC 5160-1-01
J1786
J3060
J3385

Clinical and Administrative Context

Intravenous enzyme replacement therapies (imiglucerase, taliglucerase, velaglucerase) are established treatments for Type 1 Gaucher disease. UnitedHealthcare relies on InterQual specialty drug criteria to define specific clinical eligibility for these products.

Defined Terms

Definitions

InterQualThird‑party clinical decision support criteria referenced by UnitedHealthcare to determine medical necessity for specialty drug therapies.

OAC 5160-1-01Ohio Administrative Code section referenced for medical necessity evaluation of services stated as unproven or subject to coverage/quantity limits.

Policy Changes

08/01/2025Policy updatedLatest

Routine review performed; no content changes — archived previous policy version CSOH2024D0048.B.

Policy Summary

PayerUnitedHealthcare

PolicyIntravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease (for Ohio Only)

Policy CodePolicy CSOH2025D0048.C

Change TypeRoutine reviewno content changes

Effective DateAug 1, 2025

Next Review Date

SourceLink

On This Page

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease (for Ohio Only)

Medically Necessary / Coverage Determination

Relevant Billing Codes

What Providers Must Do

Clinical and Administrative Context

Defined Terms

Other Policies to Review

Policy Changes