Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after February 1, 2022, prior authorization is required for aducanumab-avwa (Aduhelm) (procedure code J0172).
Aducanumab-avwa (Aduhelm) is an amyloid-beta directed antibody indicated to treat Alzheimer’s disease by reducing amyloid-beta plaques.
Requests for Initial Therapy
Initial therapy requests for aducanumab-avwa (Aduhelm) may be approved for a six-month period if all the following criteria are met:
- The client has a confirmed diagnosis of Alzheimer’s disease (diagnosis code G300, G301, G308, or G309).
- The prescriber attests that other forms of dementia except Alzheimer’s disease have been ruled out by appropriate lab or other diagnostic testing.
- The prescriber confirms that amyloid-beta plaques are present.
- Clinical testing must confirm that the client has mild cognitive impairment caused by Alzheimer’s disease or a mild stage of Alzheimer’s disease.
- The client must not be currently taking any anti-coagulant (except for aspirin at a prophylactic dose or less) or have a history of a clotting disorder.
- Documentation shows that the client has received a baseline magnetic resonance imaging (MRI) scan of the brain within the year prior to initiating treatment.
Additional monitoring requirements during the treatment period are as follows:
- The prescriber must monitor for amyloid-related imaging abnormalities (ARIA) during the first eight doses of treatment, particularly during titration.
- The prescriber attests that a brain MRI prior to the 7th and 12th infusions will be obtained to check for ARIA.
- Clients with severe amyloid-related imaging abnormalities hemosiderin deposition (ARIA-H) may continue therapy only if radiographic stabilization has been confirmed by a follow-up brain MRI and it is supported by clinical evaluation.
Requests for Renewal or Continuation of Therapy
For renewal or continuation of therapy requests, the client must meet all the following requirements:
- The client continues to meet the initial approval criteria.
- The client has not progressed to moderate or severe dementia caused by Alzheimer’s disease.
- The client has experienced radiographic stabilization compared to baseline or a positive clinical response to therapy, demonstrated by no increase in amyloid plaques.
- Documentation shows that a brain MRI prior to the 7th and 12th infusions was obtained to check for ARIA.
- The client has not experienced any complications or unacceptable toxicities during aducanumab-avwa (Aduhelm) treatment.
Additional Information About Aducanumab-avwa (Aduhelm)
For additional information about aducanumab-avwa (Aduhelm), providers may refer to the following resources:
- An expert panel recommendation regarding the use of aducanumab-avwa (Aduhelm).
- An American Academy of Neurology (AAN) position statement.
- AAN guidance on how to talk to patients about aducanumab-avwa (Aduhelm).
- An Institute for Clinical and Economic Review draft report about the effectiveness and value of aducanumab in treating Alzheimer’s.
- The Biogen website.
For more information, call the TMHP Contact Center at 800-925-9126.