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 September 1, 2022, prior authorization criteria will change for some chimeric antigen receptor (CAR) T-cell infusion therapies.
Axicabtagene Ciloleucel (Yescarta)
Prior authorization approval for adult clients with relapsed or refractory follicular lymphoma (FL) after two or more lines of systemic therapy will be considered when the client has a histologically confirmed diagnosis of one of the following additional types of follicular lymphoma:
Diagnosis Codes |
||||||
C8210 |
C8211 |
C8212 |
C8213 |
C8214 |
C8215 |
C8216 |
C8217 |
C8218 |
C8219 |
C8220 |
C8221 |
C8222 |
C8223 |
C8224 |
C8225 |
C8226 |
C8227 |
C8228 |
C8229 |
C8230 |
C8231 |
C8232 |
C8233 |
C8234 |
C8235 |
C8236 |
C8237 |
C8238 |
C8239 |
C8240 |
C8241 |
C8242 |
C8243 |
C8244 |
C8245 |
C8246 |
C8247 |
C8248 |
C8249 |
C8250 |
C8251 |
C8252 |
C8253 |
C8254 |
C8255 |
C8256 |
C8257 |
C8258 |
C8259 |
C8260 |
C8261 |
C8262 |
C8263 |
C8264 |
C8265 |
C8266 |
C8267 |
C8268 |
C8269 |
C8280 |
C8281 |
C8282 |
C8283 |
C8284 |
C8285 |
C8286 |
C8287 |
C8288 |
C8289 |
C8290 |
C8291 |
C8292 |
C8293 |
C8294 |
C8295 |
C8296 |
C8297 |
C8298 |
C8299 |
Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.21.1, “Prior Authorization Criteria for Axicabtagene Ciloleucel (Yescarta)” for additional diagnosis codes that may be prior authorized.
Lisocabtagene Maraleucel (Breyanzi)
Prior authorization approval for adult clients with large B-cell lymphoma will be considered when the client meets one of the following criteria:
- The client has refractory disease to first-line chemoimmunotherapy or relapse within 12 months of first-line chemoimmunotherapy.
- The client has refractory disease to first-line chemoimmunotherapy or relapse after first-line chemoimmunotherapy and is not eligible for hematopoietic stem cell transplant (HSCT) due to comorbidities or age.
- The client has relapsed or refractory disease after two or more lines of systemic therapy.
Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.21.4, “Prior Authorization Criteria for Lisocabtagene Maraleucel (Breyanzi)” for additional requirements.
Tisagenlecleucel (Kymriah)
Tisagenlecleucel (Kymriah) (procedure code Q2042) will be indicated to treat adult clients with relapsed or refractory FL after two or more lines of systemic therapy. Prior authorization approval will be considered when all the following criteria are met:
- The client is 18 years of age or older.
- The client has relapsed or refractory disease, defined as progression after two or more 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 a histologically confirmed diagnosis of one of the following types of follicular lymphoma:
Diagnosis Codes |
||||||
C8200 |
C8201 |
C8202 |
C8203 |
C8204 |
C8205 |
C8206 |
C8207 |
C8208 |
C8209 |
C8210 |
C8211 |
C8212 |
C8213 |
C8214 |
C8215 |
C8216 |
C8217 |
C8218 |
C8219 |
C8220 |
C8221 |
C8222 |
C8223 |
C8224 |
C8225 |
C8226 |
C8227 |
C8228 |
C8229 |
C8230 |
C8231 |
C8232 |
C8233 |
C8234 |
C8235 |
C8236 |
C8237 |
C8238 |
C8239 |
C8240 |
C8241 |
C8242 |
C8243 |
C8244 |
C8245 |
C8246 |
C8247 |
C8248 |
C8249 |
C8250 |
C8251 |
C8252 |
C8253 |
C8254 |
C8255 |
C8256 |
C8257 |
C8258 |
C8259 |
C8260 |
C8261 |
C8262 |
C8263 |
C8264 |
C8265 |
C8266 |
C8267 |
C8268 |
C8269 |
C8280 |
C8281 |
C8282 |
C8283 |
C8284 |
C8285 |
C8286 |
C8287 |
C8288 |
C8289 |
C8290 |
C8291 |
C8292 |
C8293 |
C8294 |
C8295 |
C8296 |
C8297 |
C8298 |
C8299 |
Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.21.5, “Prior Authorization Criteria for Tisagenlecleucel (Kymriah)” for additional treatment indications that may be prior authorized.
For more information, call the TMHP Contact Center at 800-925-9126.