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New Treatment Indications for Some CAR T-Cell Infusion Therapies Effective July 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 July 1, 2022, treatment indications will change for axicabtagene ciloleucel (Yescarta) (procedure code Q2041) and brexucabtagene autoleucel (Tecartus) (procedure code Q2053).

Axicabtagene Ciloleucel (Yescarta)

Axicabtagene ciloleucel (Yescarta) (procedure code Q2041) will be indicated to treat adult clients with large B-cell lymphoma that is refractory to first-line chemoimmunotherapy or that relapses within 12 months of first-line chemoimmunotherapy.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.21.1, “Prior Authorization Criteria for Axicabtagene Ciloleucel (Yescarta),” for additional treatment indications that may be prior authorized.

Prior authorization for all treatment indications will be considered when the client is 18 years of age or older and has a histologically confirmed diagnosis of one of the following types of large B-cell lymphoma:

Diagnosis Codes

C8330

C8331

C8332

C8333

C8334

C8335

C8336

C8337

C8338

C8339

C8510

C8520

Brexucabtagene Autoleucel (Tecartus)

Brexucabtagene autoleucel (Tecartus) (procedure code Q2053) will also be indicated to treat adult clients with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL).

Prior authorization will be considered when all of the following criteria are met:

  • The client has a histologically confirmed diagnosis of relapse or refractory B-cell precursor ALL (diagnosis codes C9100, C9101, and C9102).
  • The client is 18 years of age or older.
  • 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 chimeric antigen receptor (CAR)-T therapy.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.21.2, “Prior Authorization for Brexucabtagene autoleucel (Tecartus),” for prior authorization criteria for clients with mantle cell lymphoma.

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