Skip to main content

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

Last updated on 10/22/2021

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 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:

  • Axicabtagene ciloleucel (Yescarta) (procedure code Q2041)
  • Brexucabtagene autoleucel (Tecartus) (procedure code Q2053)
  • Tisagenlecleucel (Kymriah) (procedure code Q2042)

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