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Mogamulizumab-kpkc (Poteligeo) a Benefit of Texas Medicaid Effective March 1, 2019

Last updated on 5/22/2019

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after March 1, 2019, mogamulizumab-kpkc (Poteligeo) procedure code C9038 is a benefit of Texas Medicaid. Mogamulizumab-kpkc (Poteligeo) is a CCR4-directed monoclonal antibody indicated for the treatment of an adult patient with relapsed or refractory mycosis fungoides or Sézary syndrome after at least one prior systemic therapy.

Mogamulizumab-kpkc (Poteligeo) requires prior authorization, and must be prescribed by, or in consultation with, an oncologist or hematologist. Mogamulizumab-kpkc (Poteligeo) (procedure code C9038) may be approved for a duration of every 12 months.

Prior authorization requests for procedure code C9038 must be submitted to the Special Medical Prior Authorization unit using the Special Medical Prior Authorization (SMPA) Request Form.

The SMPA Request Form must be completed, signed, and dated by the prescribing provider. The SMPA form will not be accepted beyond 90 days from the date of the prescribing provider's signature.

Documentation of the client's dosage, administration schedule, number of injections to be administered during the prior authorization period, requested units per injection, and the dosage calculation must be submitted in Section C of the SMPA Request Form under Statement of Medical Necessity.

The completed SMPA Request Form must be maintained by the prescribing provider in the client's medical record and is subject to retrospective review.

Prior Authorization Criteria

Prior authorization for initial therapy using mogamulizumab-kpkc (Poteligeo) infusion will be considered when all of the following criteria are met:

  • The client is 18 years of age or older
  • The client has relapsed or refractory disease
  • The client has received at least one prior systemic therapy
  • The client has a histologically confirmed diagnosis of Mycosis fungoides or Sézary syndrome
Diagnosis Codes for Mycosis Fungoides
C8400 C8401 C8402 C8403 C8404 C8405 C8406
C8407 C8408 C8409        
Diagnosis Codes for Sézary syndrome
C8410 C8411 C8412 C8413 C8414 C8415 C8416
C8417 C8418 C8419        

For renewal or continuation of therapy, the client must meet all the following requirements:

  • The client demonstrates partial or complete response to treatment or stabilization of disease, shown by a decrease in spread or size of the tumor
  • The absence of unacceptable drug toxicity, such as dermatological toxicity, severe infection, infusion reactions (Stevens-Johnson Syndrome or toxic epidermal necrolysis), and life-threatening autoimmune complications

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