Moxetumomab pasudotox-tdfk (Lumoxiti) Procedure Code C9045 is a Benefit of Texas Medicaid Effective April 1, 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 April 1, 2019, clinician-administered drug procedure code C9045 Moxetumomab pasudotox-tdfk (Lumoxiti) will be a benefit of Texas Medicaid.

Moxetumomab pasudotox-tdfk (Lumoxiti) is a CD-22 directed cytotoxin indicated for the treatment of relapsed or refractory Hairy Cell Leukemia (HCL) in adults who have received at least two prior systemic therapies, including treatment with a purine nucleoside analog (PNA).

Moxetumomab pasudotox-tdfk (Lumoxiti) must be prescribed by, or in consultation with, an oncologist or hematologist.

Authorization Requirements

Prior authorization is required for moxetumomab pasudotox-tdfk (Lumoxiti) procedure code C9045. Prior authorization may be granted for a duration of 6 months (6 cycles).

Prior authorization approval for moxetumomab pasudotox-tdfk (Lumoxiti) infusion will be considered once all the following criteria are met:

• The client is 18 years of age or older.
• The client has a confirmed diagnosis of Hairy Cell Leukemia (diagnosis codes C9140 and C9142).
• The client has relapsed or refractory disease.
• The client has received at least two prior systemic therapies, including treatment with a PNA.
• The client does not have severe renal impairment, defined as creatinine clearance (CrCl) or 29 ml/min or less.

Prior authorization requests for procedure code C9045 must be submitted to the Special Medical Prior Authorization (SMPA) department at TMHP using the Special Medical Prior Authorization (SMPA) Request Form.

An 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.

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

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 the Section C of the SMPA Request Form under the Statement of Medical Necessity.

Prior authorization requests must be submitted to the TMHP Prior Authorization Department by mail, fax, or the electronic portal. Prescribing or ordering providers, dispensing providers, the client’s responsible adults, and clients may sign prior authorization forms and supporting documentation using electronic or wet signatures.

To facilitate determination of medical necessity and avoid unnecessary denials, the prescribing provider must submit correct and complete information, including documentation for medical necessity for the equipment or supplies requested, procedure codes, and numerical quantities for services requested. The provider must maintain documentation of medical necessity in the client’s medical record.

Reimbursement

Procedure code C9045 may be reimbursed for medical services rendered to clients who are 18 years of age and older as follows:

Exclusions

Moxetumomab pasudotox-tdfk is not a benefit for clients who have renal impairment with CrCl <29 ml/min.

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