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Prior Authorization Criteria for Enzyme Replacement Therapy (ERT) Procedure Code C9085 Effective March 1, 2022

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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, precertification, 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 March 1, 2022, prior authorization is required for enzyme replacement therapy procedure code C9085.

ERT will replace Alglucosidase Alfa in the Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, section 7.4.

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