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Prior Authorization Criteria to Change for Some CAR T-Cell Infusion Therapies Effective September 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 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.