Skip to main content

Lecanemab-irmb (Leqembi) a Benefit of Texas Medicaid Effective July 6, 2023

Last updated on

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after July 6, 2023, lecanemab-irmb (Leqembi) (procedure code J0174) is a benefit of Texas Medicaid when submitted with diagnosis code G300, G301, G308, or G309. Procedure code J0174 may be reimbursed as follows:

  • To physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), and physician providers for services rendered in the office setting
  • To hospital providers for services rendered in the outpatient hospital setting

Lecanemab-irmb (Leqembi) is an amyloid-beta–directed antibody indicated to treat Alzheimer’s disease (AD) by reducing amyloid-beta plaques.

Prior Authorization Requirements for Lecanemab-irmb (Leqembi)

Beginning November 1, 2023, prior authorization will be required for lecanemab-irmb (Leqembi).

Requests for Initial Therapy

Initial therapy for lecanemab-irmb (Leqembi) may be approved for a 6-month duration if all the following criteria are met:

  • The client has a confirmed diagnosis of Alzheimer’s disease (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 presence of amyloid-beta plaques.
  • Clinical testing must confirm that the client has mild cognitive impairment caused by Alzheimer’s disease or mild stage of Alzheimer’s disease.
  • Documentation confirms that the client has received a baseline brain magnetic resonance imaging (MRI) prior to initiating treatment (within the past year) to evaluate for preexisting amyloid-related imaging abnormalities (ARIA).

The following are the monitoring requirements during the treatment period:

  • The prescriber must monitor for ARIA during the first 14 weeks of treatment.
  • The prescriber attests to obtain a brain MRI prior to the 5th, 7th, and 14th infusion to check for ARIA.
  • Clients with severe ARIA with hemosiderin deposition (ARIA-H) may continue therapy only if radiographic stabilization has been confirmed by a follow-up brain MRI and supported by clinical evaluation.

Requests for Renewal or Continuation of Therapy

For renewal or continuation of therapy of lecanemab-irmb (Leqembi), the client must meet the following requirements:

  • The client continues to meet all the initial authorization approval criteria.
  • The client has not progressed to moderate or severe dementia caused by Alzheimer’s disease.
  • The client has experienced positive clinical response to therapy as demonstrated by no increase in amyloid plaque or radiographic stabilization as compared to baseline.
  • Documentation of a brain MRI prior to the 5th, 7th, and 14th infusions to check for ARIA is present.
  • The client has not experienced any complications or unacceptable toxicities during lecanemab-irmb (Leqembi) treatment.

For more information, call the TMHP Contact Center at 800-925-9126.