Skip to main content

Effective March 1, 2019, New Prior Authorization Criteria for Inotuzumab Ozogamicin (Besponsa) for the CSHCN Services Program

Last updated on 2/1/2019

Effective for dates of service on or after March 1, 2019, prior authorization criteria for inotuzumab ozogamicin (Besponsa) procedure code J9229 will change for the Children with Special Health Care Needs (CSHCN) Services Program.

Inotuzumab ozogamicin is indicated for the treatment of relapsed or refractory precursor B-cell acute lymphoblastic leukemia (ALL), and must be prescribed by an oncologist or in consultation with an oncologist.

Procedure code J9229 requires prior authorization and may be approved when all of the following criteria is met:

  • The client has a confirmed diagnosis of precursor B-cell ALL.
  • The client must have relapsed or refractory disease.
  • The client is 18 years of age or older.
  • The provider agrees to monitor the client for signs and symptoms of hepatic veno-occlusive disease (VOD) during the duration of Besponsa therapy.

Requests for prior authorization must be submitted by the ordering provider using the CSHCN Services Program Authorization and Prior Authorization Request form.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.