Prior Authorization Criteria for CAR T-Cell Therapy to Change Effective December 1, 2021
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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 December 1, 2021, prior authorization criteria will change for chimeric antigen receptor (CAR) t-cell therapy for Texas Medicaid.
New Prior Authorization Requirements
Prior authorization will be required for idecabtagene vicleucel (ABECMA) (procedure code C9081) and lisocabtagene maraleucel (Breyanzi) (procedure code Q2054).
Idecabtagene Vicleucel (ABECMA)
Prior authorization approval of idecabtagene vicleucel (ABECMA) (procedure code C9081) infusion therapy will be considered when all of the following criteria are met:
The client is 18 years of age or older.
The client has a histologically confirmed diagnosis of relapse or refractory multiple myeloma (diagnosis codes C9000 and C9002).
The client must have received four or more prior lines of the following therapies before treatment with idecabtagene vicleucel:
An immunomodulatory agent
A proteasome inhibitor
An anti-CD-38 monoclonal antibody
The client does not have primary central nervous system lymphoma/disease.
The client does not have an active infection or inflammatory disorder.
The client has not received prior CAR-T therapy.
Idecabtagene vicleucel (ABECMA) (procedure code C9081) will be limited to once per lifetime.
Lisocabtagene Maraleucel (Breyanzi)
Prior authorization approval of lisocabtagene maraleucel (Breyanzi) (procedure code Q2054) infusion therapy will be considered when all of the following criteria are met:
The client has a histologically confirmed diagnosis of diffuse large B-cell lymphoma, including diffuse large B-cell lymphoma not otherwise specified (including DLBCL arising from indolent lymphoma), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, or follicular lymphoma grade 3B.
The client is 18 years of age or older.
The client has relapsed or refractory disease after receiving at least two lines of systemic therapy.
The client does not have primary central nervous system lymphoma/disease.
The client does not have an active infection or inflammatory disorder.
The client has not received prior CD-19 directed CAR-T therapy.
The client has one of the following lymphoma diagnosis codes:
Diagnosis Codes
C8240
C8241
C8242
C8243
C8244
C8245
C8246
C8247
C8248
C8249
C8250
C8330
C8331
C8332
C8333
C8334
C8335
C8336
C8337
C8338
C8339
C8390
C8391
C8392
C8393
C8394
C8395
C8396
C8397
C8398
C8399
C8510
C8511
C8512
C8513
C8514
C8515
C8516
C8517
C8518
C8519
C8520
C8521
C8522
C8523
C8524
C8525
C8526
C8527
C8528
C8529
C8580
C8581
C8582
C8583
C8584
C8585
C8586
C8587
C8588
C8589
Lisocabtagene maraleucel (Breyanzi) (procedure code Q2054) will be limited to once per lifetime.
Additional Prior Authorization Requirement
In addition to current prior authorization requirements, the client must not have an active infection or inflammatory disorder for treatment with the following infusion therapies:
For more information, call the TMHP Contact Center at 800-925-9126.
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