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TMPPM Update for Enzyme Replacement Therapy Benefits

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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.

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

Enzyme Replacement Therapy (ERT)

The following ERT benefit information will be added:

ERT is a medical treatment that replaces a specific enzyme that is deficient or absent in the body.

The following ERT benefits will require prior authorization:

  • Agalsidase beta (Fabrazyme) is indicated in clients who are 2 years of age or older with Fabry disease and may be reimbursed with diagnosis code E7521.
  • Alglucosidase alfa (Lumizyme) is indicated for clients with Pompe disease (GAA deficiency) may be reimbursed with diagnosis code E7402.
  • Avalglucoside alfa-ngpt (Nexviazyme) is indicated for clients who are 1 year of age or older with late onset Pompe disease (lysosomal acid alpha-glucosidase [GAA] deficiency) and may be reimbursed with diagnosis code E7402.
  • Cerliponase alfa (Brineura) is indicated to slow the loss of ambulation in symptomatic pediatric clients 3 years of age or older with late infantile neuronal ceroid lipofuscinosis type 2 (CLN2) and may be reimbursed with diagnosis code E754.
  • Elosulfase alfa (Vimizim) is a hydrolytic lysosomal glycosaminoglycan- (GAG) specific enzyme indicated for clients who are 5 years of age or older with mucopolysaccharidosis type IVA and may be reimbursed with diagnosis code E76210.
  • Galsulfase (Naglazyme) is a hydrolytic lysosomal glycosaminoglycan- (GAG) specific enzyme indicated for clients with mucopolysaccharidosis VI (MPS VI; Maroteaux-Lamy syndrome) and may be reimbursed with diagnosis code E7629.
  • Idursulfase (Elaprase) is a hydrolytic lysosomal glycosaminoglycan- (GAG) specific enzyme indicated for clients with Hunter syndrome (mucopolysaccharidosis II [MPS II]) and may be reimbursed with diagnosis code E761.
  • Imiglucerase (Cerezyme) is indicated for long-term ERT for clients who are 2 years of age or older with a confirmed diagnosis of Type 1 Gaucher disease (diagnosis code E7522) that results in one or more of the following conditions:
    • Anemia (low red blood cell count)
    • Thrombocytopenia (low blood platelet count)
    • Bone disease
    • Hepatomegaly or splenomegaly (enlarged liver or spleen)
  • Laronidase (Aldurazyme) is indicated in clients with Hurler and Hurler-Scheie forms of mucopolysaccharidosis I (MPS I) and clients with the Scheie form who have moderate to severe symptoms and may be reimbursed with diagnosis codes E7601, E7602, and E7603.
  • Protein C concentrate, human (Ceprotin) is indicated in pediatric and adult clients with severe congenital protein C deficiency for the prevention and treatment of venous thrombosis and purpura fulminans and may be reimbursed with diagnosis cod D6859.
  • Sebelipase alfa (Kanuma) is indicated for the treatment of pediatric and adult clients with a diagnosis of lysosomal acid lipase (LAL) deficiency and may be reimbursed with diagnosis code E755.
  • Taliglucerace alfa (Elelyso) is indicated for long-term ERT for adult clients with Type 1 Gaucher disease and may be reimbursed with diagnosis code E7522.
  • Velaglucerase alfa (VPRIV) is indicated for long-term ERT for clients with Type 1 Gaucher disease and may be reimbursed with diagnosis code E7522.

Reimbursement

The following procedure codes may be reimbursed for ERT services:

Procedure Codes

C9085

J0180

J0221

J0567

J1322

J1458

J1743

J1786

J1931

J2724

J2840

J3060

J3385

         

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