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Prior Authorization Criteria for Enzyme Replacement Therapy Procedure Codes C9167 and J1203 Effective May 1, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after May 1, 2024, prior authorization criteria will be required for enzyme replacement therapy (ERT) apadamtase alfa (Adzynma) procedure code C9167 and cipaglucosidase alfa-atga (Pombiliti) procedure code J1203.

Prior Authorization Requirements

Apadamtase alfa (Adzynma) procedure code C9167 is indicated in pediatric and adult clients for prophylactic or on-demand ERT for congenital thrombotic thrombocytopenic purpura (cTTP) and may be reimbursed with diagnosis code D6942.

Cipaglucosidase alfa-atga (Pombiliti) procedure code J1203 is indicated to treat adult clients with Pompe disease (lysosomal acid alpha-glucosidase [GAA] deficiency) who weigh over 40 kilograms, are not improving on current ERT, and may be reimbursed with diagnosis code E7402.

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