Skip to main content

Prior Authorization Criteria for Afamitresgene Autoleucel (Tecelra) Effective May 1, 2025

Last updated on

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after May 1, 2025, prior authorization will be required for afamitresgene autoleucel (Tecelra), procedure code Q2057.

Requirements for Treatment

Afamitresgene autoleucel (Tecelra) is a melanoma-associated antigen A4 (MAGE-A4)-directed genetically modified autologous T-cell immunotherapy and is administered as a single intravenous infusion. Afamitresgene autoleucel (Tecelra) is indicated to treat clients who meet all the following requirements:

  • The client is 18 years of age or older.
  • The client has a diagnosis of unresectable or metastatic synovial sarcoma.
  • The client’s tumor is positive for human leukocyte antigen HLA-A*02:01P, HLA-A*02:02P, HLA-A*02:03P, or HLA-A*02:06P.
  • The client’s tumor expresses the MAGE-A4 antigen as determined by U.S. Food and Drug Administration (FDA)-approved or FDA-cleared companion diagnostic devices.
  • The client is not heterozygous or homozygous for HLA-A*02:05P.
  • The client has experienced disease progression following at least one or more prior systemic chemotherapy.
  • The client has not received prior treatment with chimeric antigen receptor (CAR) T-cell therapy.
  • The client has not had a prior hematopoietic stem cell transplant (HSCT).
  • The client does not have any active or clinically significant infections or inflammatory disorders.

Required Monitoring Parameters

The client must be monitored for the following parameters for at least seven days following afamitresgene autoleucel (Tecelra) treatment, with continued monitoring for at least four weeks:

  • Signs and symptoms of cytokine release syndrome (CRS)
  • Signs and symptoms of immune effector cell-associated neurotoxicity syndrome (ICANS)

Reimbursement

Afamitresgene autoleucel (Tecelra), procedure code Q2057, will be limited to one transfusion treatment per lifetime and must be billed with one of the following diagnosis codes:

Diagnosis Codes
C380C381C382C383C384C388C481
C482C488C490C4910C4911C4912C4920
C4921C4922C493C494C495C496C498
C499      

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