CurrentUnitedHealthcarePolicy CSOH2026D0023.D

Lemtrada (Alemtuzumab) — Ohio Medical Benefit Drug Policy

Governs medical benefit coverage and medical necessity determination for Lemtrada (alemtuzumab) for UnitedHealthcare Community Plan members in Ohio; applies to providers requesting coverage and prior authorization for the drug.

Policy Summary

PayerUnitedHealthcare

PolicyLemtrada (Alemtuzumab) — Ohio Medical Benefit Drug Policy

Policy CodePolicy CSOH2026D0023.D

Change TypeRoutine reviewno content changes

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests demonstrating medical necessity per the current InterQual guideline for alemtuzumab.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

1HCPCS code listed for Lemtrada

OhioState-specific applicability

InterQualClinical criteria source referenced

Coverage Criteria

Medical necessity (InterQual-referenced)

Covered when members meet the InterQual specialty Rx non-oncology alemtuzumab criteria.

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InterQual-based coverage: Member meets all applicable clinical criteria in the current InterQual guideline for alemtuzumab (Lemtrada)refer to InterQual

Detailed inclusion/exclusion and sequencing rules are in InterQual and must be consulted

This policy applies only to members and services in the state of Ohio. Requests for services that are described as unproven or that are subject to coverage or quantity limits will be evaluated for medical necessity under Ohio Administrative Code 5160-1-01. Providers should not assume that inclusion of a code in this policy guarantees coverage; federal, state, contractual, and other applicable rules govern final benefit determination.

This document does not list explicit "not medically necessary" conditions. The policy underwent a routine review with no content changes and archived the prior version. Clinical determinations that a request is not medically necessary are made using the current InterQual criteria and, when applicable, Ohio Administrative Code requirements.

Coding

Applicable HCPCS CodesHCPCS

J0202

Injection, alemtuzumab, 1 mg (Lemtrada)

Policy code listing completeness

Listed HCPCS codeJ0202 — Injection, alemtuzumab, 1 mg (Lemtrada)

Scope of code listThe code list is provided for reference purposes only and may not be all inclusive

Coding does not guarantee coverageListing a code does not imply the service is covered or that claim payment is guaranteed; coverage is determined by federal, state, contractual requirements and applicable laws

Use with other policiesOther policies and guidelines may apply to determination of coverage and reimbursement

Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required; coverage is determined by medical necessity using the current InterQual criteria for alemtuzumab (Lemtrada). Providers should obtain prior authorization for HCPCS J0202 before administration.

Prior authorization required for HCPCS J0202
Coverage determined per current InterQual criteria

Denial Risk

Denial Triggers

Requests may be denied if the submitted clinical information does not meet the InterQual medical necessity criteria, if the requested service is considered unproven, or if the request exceeds coverage or quantity limits as evaluated under Ohio rules and any applicable contractual requirements.

Denials likely when InterQual criteria are not met
Denials possible for services considered unproven or experimental
Denials for requests exceeding coverage or quantity limits under Ohio rules or contract

Documentation Required

Required Documentation

Providers must submit documentation that supports medical necessity and aligns with federal, state (OAC), and contractual requirements. Documentation may include but is not limited to: relevant clinical notes, prior treatment history, diagnostic test results, and rationale for use relative to InterQual criteria.

Clinical history and relevant progress notes
Prior treatment records and sequencing (including prior disease-modifying therapies)
Relevant diagnostic test results and imaging
Completed prior authorization form and any supplemental clinical questionnaires

Step Therapy

Step Therapy / Sequencing

Refer to the InterQual guideline for any step therapy or sequencing requirements prior to approval. Approval may require documentation of failure, intolerance, or contraindication to specified prior therapies as outlined in InterQual.

Follow InterQual for step therapy or sequencing requirements
Provide documentation of failure, intolerance, or contraindication to prior required therapies when applicable

Definitions

InterQual criteria

Clinical criteria sourceInterQual guideline: CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada)

Coverage determinationLemtrada is proven and medically necessary when members meet the conditions outlined in the current InterQual criteria

Where to find criteriaRefer to the current release of the InterQual guideline for Lemtrada for detailed medical necessity clinical coverage criteria

Initial Therapy Criteria

Initial therapy

Initial therapy coverage requires meeting InterQual initial patient criteria.

Initial therapy: Member meets initial patient criteria per current InterQual guideline for alemtuzumabrefer to InterQual

Policy refers to InterQual for detailed initial therapy requirements.

Continuation Therapy Criteria

Continuation therapy

Continuation therapy coverage is determined by whether the patient continues to meet InterQual criteria on the current release.

Continuation coverage: Patient continues to meet InterQual criteria for ongoing therapyrefer to InterQual

No separate continuation rules are specified in this policy document.

Step Therapy

Step	Requirement
1	Any step therapy or sequencing requirements are defined within the current InterQual guideline for alemtuzumab (Lemtrada); refer to the InterQual Specialty Rx Non‑Oncology Alemtuzumab (Lemtrada) criteria for specific step therapy details.

Site of Care

Note

Infusion center/site‑of‑care — follow contract and InterQual

The policy does not specify site‑of‑care (infusion center) restrictions; follow the member's contract, medical necessity determinations, and InterQual guidance when selecting the infusion setting.

Verify contract terms and InterQual medical necessity for site‑of‑care decisions.
Document the chosen infusion setting and rationale in the medical record per payer/contract requirements.

Background

Alemtuzumab (Lemtrada) is a disease-modifying therapy referenced in this policy. Coverage and medical necessity determinations for Lemtrada are made by applying the InterQual specialty pharmacy non-oncology guideline referenced in the policy; providers must consult the current InterQual criteria for the specific clinical scenarios, indications, and sequencing requirements that meet coverage.