Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.11 Alglucosidase Alfa (Myozyme)

9.2.39.11
Alpha-glucosidase, a recombinant human enzyme alpha-glucosidase (rhGAA), is an essential enzyme for normal muscle development and function. Aglucosidase alfa may be a benefit of Texas Medicaid for clients of any age who are diagnosed with glycogen storage disease Type II (GSD Type II, also known as Pompe disease), using procedure codes J0220 and J0221. The most appropriate diagnosis code must be indicated on the prior authorization request and on the claim.
Prior authorization is required for alglucosidase alfa and documentation must include all of the following:
Laboratory evidence of acid alpha-glucosidase (GAA) deficiency, (i.e., below the laboratory-defined cut-off value as determined by the laboratory performing the GAA enzyme activity assay). Tissues used for determination of GAA deficiency may include blood, muscle, or skin fibroblasts.
The physician must maintain supporting documentation in the client’s medical record.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.