Medicare AdvantagePrior AuthMedium impact
Lumizyme® (alglucosidase alpha) (Revised)
Humana·KY, SC · Genetics, Pediatrics, Internal Medicine +2 more·Medicaid
Effective date
Jan 1, 2011
We identified it
Jul 22, 2026
Summary
This is a revised Humana prior authorization policy for Lumizyme (alglucosidase alpha) for treatment of Pompe disease, effective for Medicare and Medicaid (Kentucky and South Carolina) members. The policy requires prior authorization and establishes that members must have a confirmed diagnosis of Pompe disease to receive coverage. The revision date of July 22, 2026 indicates this is a current policy update that supersedes any previous guidance.
Action Required
By August 15, 2026: Billing team must update prior authorization procedures to require confirmation of Pompe disease diagnosis (ICD-10 code E74.02 or equivalent) for all Lumizyme (alglucosidase alpha) intravenous solution requests submitted to Humana Medicare and Medicaid plans in Kentucky and South Carolina. Configure billing software to flag Lumizyme claims for mandatory prior authorization review before submission. Providers must document the member's Pompe disease diagnosis clearly on all authorization requests. Note that this is an orphan drug with black box warnings for anaphylactic reactions and immune-mediated reactions; ensure clinical staff are aware of monitoring requirements during infusion. Claims submitted without prior authorization or without documented Pompe disease diagnosis will be denied.