Skip to main content

You must have JavaScript enabled in order to access this part of the site. Please enable JavaScript and then reload this page in order to continue.

Prior Authorization Criteria for Denileukin Diftitox-cxdl (Lymphir) Effective April 1, 2026

Last updated on

Effective for dates of service on or after April 1, 2026, prior authorization will be required for denileukin diftitox-cxdl (Lymphir) (procedure code J9161).

Denileukin diftitox-cxdl (Lymphir) is an IL-2 receptor-directed cytotoxin indicated for the treatment of adult patients with relapsed or refractory Stage I to III cutaneous T-cell lymphoma (CTCL) after at least one prior systemic therapy.

Denileukin diftitox-cxdl (Lymphir) is a subcutaneous injection.

Prior Authorization Criteria

Prior authorization requests for denileukin diftitox-cxdl (Lymphir) must be submitted on the Special Medical Prior Authorization (SMPA) Request Form.

Requests for Initial Therapy

Initial therapy may be approved for a 12-month duration if all the following criteria are met:

  • The client is 18 years of age or older.
  • The client has a confirmed diagnosis of CTCL, as documented by one of the following diagnosis codes:
Diagnosis Codes
C8400C8401C8402C8403C8404C8405C8406C8407
C8408C8409C8410C8411C8412C8413C8414C8415
C8416C8417C8418C8419C84A0C84A1C84A2C84A3
C84A4C84A5C84A6C84A7C84A8C84A9C84AA 
  • The client’s lymphoma is categorized as Stage I to III.
  • The client’s CTCL is relapsed or refractory after at least one prior systemic treatment.
  • The client’s serum albumin level must be greater than 3 g/dL before the treatment cycle.
  • The prescriber attests to counseling female clients of childbearing age regarding the use of an effective method of contraception during treatment with denileukin diftitox-cxdl (Lymphir), as there may be potential risk to the fetus.

Requests for Renewal or Continuation of Therapy

For renewal or continuation of therapy of denileukin diftitox-cxdl (Lymphir), the client must meet the following requirements:

  • The client meets the initial requirements for prior authorization and is currently treated with denileukin diftitox-cxdl (Lymphir) with the absence of severe adverse reactions or unacceptable toxicity (e.g., visual impairment, infusion related reactions, or hepatotoxicity).
  • The client demonstrates partial or complete response to treatment or stabilization of disease, as shown by a decrease in spread or size of the tumor.

Required Monitoring Parameters

The client’s renal function must be monitored before the start of each treatment. If serum albumin is less than 3 g/dL, the provider must delay the administration of denileukin diftitox-cxdl (Lymphir) until the client’s serum albumin is greater than or equal to 3 g/dL.

After receiving the denileukin diftitox-cxdl (Lymphir) infusion, the client must be monitored for:

  • Signs and symptoms of capillary leak syndrome (e.g., low blood pressure or severe swelling).
  • Liver enzymes and bilirubin at baseline and during treatment, as hepatotoxicity may occur.
  • Any visual impairment throughout treatment.

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

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.