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Updated Age Ranges for COVID-19 Monoclonal Antibody Therapy Procedure Codes M0245 and M0246 Approved Through Emergency Use Authorization

Last updated on 12/22/2021

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 December 3, 2021, the U.S. Food and Drug Administration (FDA) revised the emergency use authorization (EUA) of bamlanivimab and etesevimab (previously authorized for pediatric patients 12 years and older weighing at least 40 kilograms, or about 88 pounds) to additionally authorize bamlanivimab and etesevimab administered together for the treatment of mild to moderate COVID-19 in all younger patients, including newborns, who have a positive COVID-19 test and are at high risk for progression to severe COVID-19, including hospitalization or death. The revision also authorizes bamlanivimab and etesevimab to be administered together for post-exposure prophylaxis for prevention of COVID-19 in all pediatric patients, including newborns, at high risk for progression to severe COVID-19, including hospitalization or death.

Affected claims that have dates of service from December 3, 2021, through December 9, 2021, will be reprocessed. Providers may receive an additional payment, which will be reflected on future Remittance and Status Reports. Providers are not required to appeal the claims unless the claims are denied for additional reasons after the reprocessing is complete.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.