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Prior Authorization Criteria for CAR T-Cell Therapy to Change Effective November 1, 2021

Last updated on 9/17/2021

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 November 1, 2021, prior authorization criteria will change for chimeric antigen receptor (CAR) t-cell therapy for Texas Medicaid.

Consultation or specialist requirements, as well as the certified health-care facility requirement, will be removed for axicabtagene ciloleucel (Yescarta) (procedure code Q2041), brexucabtagene autoleucel (Tecartus) (procedure code Q2053), and tisagenlecleucel (Kymriah) (procedure code Q2042).

Axicabtagene Ciloleucel (Yescarta)

Prior authorization approval for treatment of clients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy will be considered after all the following additional criteria are met:

  • The client is 18 years of age or older.
  • The client has relapsed or refractory disease, defined as progression after two or more lines of systemic therapy (which may or may not include therapy supported by autologous stem cell transplant).
  • The client has a histologically confirmed diagnosis of one of the following types of aggressive non-Hodgkin’s lymphoma (diagnosis codes C8330, C8331, C8332, C8333, C8334, C8335, C8336, C8337, C8338, and C8339).
  • The client does not have primary central nervous system lymphoma/disease.
  • The client has not received prior CD-19 directed CAR-T therapy.

Axicabtagene ciloleucel (Yescarta) is also indicated for treating adult clients with relapsed or refractory follicular lymphoma after two or more lines of systemic therapy. Prior authorization approval will be considered after all the following additional criteria are met:

  • The client is 18 years of age or older.
  • The client has relapsed or refractory disease, defined as progression after two or more lines of systemic therapy (which may or may not include therapy supported by autologous stem cell transplant).
  • The client has a histologically confirmed diagnosis of one of the following types of follicular lymphoma (diagnosis codes C8200, C8201, C8202, C8203, C8204, C8205, C8206, C8207, C8208, and C8209).
  • The client does not have primary central nervous system lymphoma/disease.
  • The client has not received prior CD-19 directed CAR-T therapy.

Brexucabtagene Autoleucel (Tecartus)

Prior authorization approval of brexucabtagene autoleucel (Tecartus) (procedure code C9073) infusion therapy will be considered when all the following criteria are met:

  • The client must have a histologically confirmed diagnosis of relapse or refractory MCL (diagnosis codes C8310, C8311, C8312, C8313, C8314, C8315, C8316, C8317, C8318 and C8319).
  • The client is 18 years of age or
  • The client does not have primary central nervous system lymphoma/disease.
  • The client has not received prior CD-19 directed CAR-T

Tisagenlecleucel (Kymriah)

Prior authorization approval of tisagenlecleucel (Kymriah) (procedure code Q2042) infusion for the treatment of clients with refractory or second relapse B-cell precursor acute lymphoblastic leukemia will be considered when all the following criteria are met:

  • The client must have a confirmed diagnosis of B-cell acute lymphoblastic leukemia (diagnosis codes C9100, C9101, and C9102).
  • The client is 25 years of age or
  • The client has a confirmed CD-19 tumor expression.
  • The disease is refractory or in second or later
  • The client has not received prior CD-19 directed CAR-T

Prior authorization approval of tisagenlecleucel (Kymriah) infusion for the treatment of clients with relapsed or refractory diffuse large B-cell lymphoma will be considered when all the following criteria are met:

  • The client has a confirmed diagnosis of relapsed or refractory large B-cell lymphoma (diagnosis codes C8330, C8331, C8332, C8333, C8334, C8335, C8336, C8337, C8338, and C8339):
    • Diffuse large B-cell lymphoma, not otherwise specified
    • High grade B-cell lymphoma
    • Diffuse large B-cell lymphoma arising from follicular lymphoma
  • The client is 18 years of age or
  • The client has relapsed or refractory disease, defined as progression after two or more lines of systemic therapy (which may or may not include therapy supported by autologous stem cell transplant).
  • The client does not have primary central nervous system lymphoma.
  • The client has not received prior CD-19 directed CAR-T

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