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 June 1, 2021, prior authorization criteria for omalizumab (Xolair) procedure code J2357 will be updated for Texas Medicaid.
Nasal Polyp Maintenance
Omalizumab is currently indicated to treat moderate to severe asthma in individuals who are 6 years of age and older, and chronic idiopathic urticaria (CIU) in individuals who are 12 years of age and older. Omalizumab will also be a benefit as an add-on maintenance treatment of nasal polyps in adult clients who are 18 years of age and older with inadequate response to nasal corticosteroids.
Documentation supporting medical necessity for maintenance treatment of nasal polyps with omalizumab (Xolair) must be submitted with the prior authorization request and include the following:
- The client has bilateral nasal polyposis confirmed by physical examination or nasal endoscopy.
- Documented failure of, or contraindication to, prior corticosteroids as monotherapy.
- Documented inadequate response to prior corticosteroid treatments.
For more information, call the TMHP Contact Center at 800-925-9126.