Changes to Prior Authorization Criteria for CAR T-Cell Therapy

Date: August 20, 2024

Attention: All Providers

Effective date: August 1, 2024

Call to action: Last updated 9/12/2024: Texas Children’s Health Plan (TCHP) would like to inform network providers that effective for dates of service on or after August 1, 2024, prior authorization criteria for Texas Medicaid changed for the chimeric antigen receptor (CAR) t-cell therapies as outlined below.

Lisocabtagene Maraleucel (Breyanzi)

The following prior authorization criteria for lisocabtagene maraleucel (Breyanzi) procedure code Q2054 will be added:

• The patient has histologically confirmed diagnosis of large B-cell lymphoma including diffuse large B-cell lymphoma (DLBCL) not otherwise specified (including DLBCL arising from indolent lymphoma), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B with one of the following: 
  • Refractory disease to first-line chemoimmunotherapy or relapse within 12 months of first-line chemoimmunotherapy 
  • 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 
  • Relapsed or refractory disease after two or more lines of systemic therapy. 
• The patient has confirmed diagnosis of relapsed or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) and has received at least two prior lines of therapy, including a Bruton tyrosine kinase (BTK) inhibitor and a B-cell lymphoma 2 (BCL-2) inhibitor.
• The patient has confirmed diagnosis of elapse or refractory follicular lymphoma and has received two or more lines of systemic therapy.
• The patient has confirmed diagnosis of relapse or refractory mantle cell lymphoma (MCL) and had received at least two prior lines of systemic therapy.
• The patient has one of the following lymphoma diagnosis codes:

Ciltacabtagene Autoleucel (Carvykti)

The Food and Drug Administration (FDA) has updated the criteria for patients who have relapsed or refractory disease and have received at least one line of systemic therapies before treatment with ciltacabtagene autoleucel (Carvykti). 

The lines of systemic therapies have decreased from four or more to at least one in the following criterion: 

• Patients have relapsed or refractory disease, are refractory to lenalidomide, and have received at least one line of the following systemic therapies before treatment with ciltacabtagene autoleucel (Carvykti): 
  • A proteasome inhibitor 
  • An immunomodulatory agent 

Idecabtagene Vicleucel (Abecma)

The number of systemic therapies has changed from four or more lines to two or more lines in the following criterion:

• The patient must have received two or more lines of the following therapies before treatment with idecabtagene vicleucel (Abecma):
  • An immunomodulatory agent 
  • A proteasome inhibitor 
  • An anti-CD-38 monoclonal antibody 

Next step for Providers: Providers are encouraged to submit authorization requests on Texas Children’s® Link since this is the most efficient way for our team to process authorizations. If providers are experiencing any barriers to submitting prior authorizations on the portal, they are encouraged to reach out to their assigned Provider Relations Liaison (PRL).

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

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