Mini-Mental Status Examination (MMSE) score of 21 - 30 (see Appendix C) or.Clinical Dementia Rating-Global Score (CDR-GS) of 0.5 or 1 (see Appendix B) or.Member must have one of the following scores at baseline on any of the following assessment tools:.Member must have objective evidence of cognitive impairment at baseline (see Appendix A) and.Member must have mild cognitive impairment due to AD or mild AD dementia and.If less than 50 years of age, member has a genetic mutation in amyloid precursor protein ( APP), presenilin-1 ( PSEN1), or presenilin-2 ( PSEN2), or other clinical documentation to support early onset AD and.Member must meet one of the following criteria: This medication must be prescribed by or in consultation with a geriatrician, neurologist, psychiatrist, or neuropsychiatrist.Īetna considers lecanemab-irmb (Leqembi) medically necessary for treatment of Alzheimer’s Disease (AD) when all of the following criteria are met: Leqembi will not be used in combination with any other amyloid beta-directed antibodies (e.g., aducanumab).Bleeding disorder that is not under adequate control (including a platelet count less than 50,000 or international normalized ratio greater than 1.5).History of transient ischemic attacks (TIA), stroke, or seizures within the past 12 months.Suspected neurodegenerative etiology of cognitive impairment other than Alzheimer’s disease (AD), including but not limited to frontotemporal lobar degeneration (FTLD) or Lewy body disease (i.e., meeting consensus criteria for possible or probable dementia with Lewy bodies).
For information on site of service for lecanemab-irmb (Leqembi), see Utilization Management Policy on Site of Care for Specialty Drug Infusions.Ĭoverage will not be provided for members with any of the following conditions: Note: Site of Care Utilization Management Policy applies. For precertification of lecanemab-irmb (Leqembi), call (866) 752-7021, or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification. Precertification of lecanemab-irmb (Leqembi) is required of all Aetna participating providers and members in applicable plan designs. For Medicare criteria, see Medicare Part B Criteria. This Clinical Policy Bulletin addresses lecanemab-irmb (Leqembi) for commercial medical plans. Number: 1026 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References