CurrentAnthemPolicy CC-0253

Aphexda (motixafortide) — stem cell mobilization for autologous transplantation

Policy governs medical benefit coverage and prior authorization criteria for Aphexda (motixafortide) used with filgrastim to mobilize hematopoietic stem cells for autologous transplantation in individuals with multiple myeloma.

Policy Summary

PayerAnthem

PolicyAphexda (motixafortide) — stem cell mobilization for autologous transplantation

Policy CodePolicy CC-0253

Change TypeCoding additions (non‑material)

Effective DateApr 1, 2024

Next Review Date

Key ActionObtain prior authorization and document age (≥18), diagnosis of multiple myeloma, planned use with filgrastim (or biosimilar/tbo), intent for autologous transplant, and that total Aphexda injections will not exceed two.

SourceLink

POLICY UPDATE CHANGES

Coding reviewed and ICD-10-CM Z52.011 and Z94.84 were added during the 02/21/2025 annual review.

HCPCS J2277 (motixafortide, 0.25 mg) and ICD-10-CM C90.00-C90.02 were added effective 04/01/2024.

2max injections per cycle

18+minimum age

J2277HCPCS

C90.00-C90.02ICD-10 range

Coverage Criteria for Aphexda (motixafortide)

Approval (Initial therapy)

Requests for Aphexda (motixafortide) may be approved if ALL of the following are met:

Initial approval criteria

Individual is 18 years or older;age >=18
Diagnosis of multiple myeloma;
Aphexda (motixafortide) is being used to mobilize autologous hematopoietic stem cells;
Used in combination with filgrastim, a filgrastim biosimilar, or tbo-filgrastim (NCCN 2A);

Policy Summary

PayerAnthem

PolicyAphexda (motixafortide) — stem cell mobilization for autologous transplantation

Policy CodePolicy CC-0253

Change TypeCoding additions (non‑material)

Effective DateApr 1, 2024

Next Review Date

SourceLink

On This Page

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After mobilization and collection, a subsequent autologous hematopoietic stem cell transplant is anticipated;

Total number of Aphexda injections does not exceed two doses total (one dose prior to first and one dose prior to third apheresis).<= 2 doses total

Requests for Aphexda (motixafortide) will not be approved when the request exceeds the approved treatment limits. Specifically, Aphexda is not approved for more than one treatment cycle (which equates to more than two doses total). Approval is limited to a single treatment cycle that includes no more than two injections (one dose prior to the first apheresis and one dose prior to the third apheresis).

The policy considers certain uses of Aphexda to be not medically necessary. Use of Aphexda as a mobilizing agent for allogeneic stem cell donors is not covered. In addition, use of Aphexda to mobilize leukemic cells is not medically necessary under this policy. Requests for these indications should be denied or redirected to appropriate alternative management.

inv-07: Maximum Aphexda injections — operational limit (≤ 2 doses total)

Operational limitMaximum of 2 Aphexda (motixafortide) injections per treatment cycle (one dose prior to first apheresis and one dose prior to third apheresis)

Approval durationOne treatment cycle (includes the two doses specified)

Disallowed excess dosingRequests exceeding one treatment cycle (more than two doses) will not be approved

Coding and Billing

Covered HCPCSHCPCSCovered

J2277

Injection, motixafortide, 0.25 mg [Aphexda]

Relevant ICD-10 Diagnosis CodesICD-10

C90.00-C90.02

Multiple Myeloma

Procedure / transplant status codesICD-10

Z52.011	Autologous donor, stem cells
Z94.84	Stem cells transplant status

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Aphexda (motixafortide). Requests may be approved only when all approval criteria are met. Denials may result if criteria are not satisfied or required documentation is missing.

Prior authorization required for Aphexda (motixafortide) (HCPCS J2277).
Approval limited to adults (≥ 18 years).
Approval requires use in combination with filgrastim, a filgrastim biosimilar, or tbo‑filgrastim.
Maximum of one treatment cycle (includes two doses total; one dose prior to first and third apheresis).
Not approved for allogeneic donors or for mobilization of leukemic cells.

Documentation Required

Required Submission Information

Documentation must clearly demonstrate the clinical criteria that support medical necessity for Aphexda. Include evidence of planned autologous transplant and planned combination with a granulocyte‑colony stimulating factor.

Patient age (≥ 18 years).
Diagnosis code(s): C90.00–C90.02 (multiple myeloma).
Planned use: mobilization of autologous hematopoietic stem cells (Z52.011, Z94.84 as applicable).
Planned concomitant agent: filgrastim, filgrastim biosimilar, or tbo‑filgrastim (per NCCN).
Treatment plan showing intent for subsequent autologous hematopoietic stem cell transplant after collection.
Planned dosing and schedule demonstrating no more than two Aphexda injections total (one dose prior to first and third apheresis) and no more than one treatment cycle.

Denial Risk

Common Denial Triggers

Common reasons a request may be denied include exceeding the allowed number of injections or treatment cycles, use for allogeneic donors or leukemic cell mobilization, or insufficient supporting documentation.

Request exceeds one treatment cycle or more than two Aphexda doses.
Aphexda requested for an allogeneic stem cell donor.
Aphexda requested to mobilize leukemic cells.
Documentation does not confirm age, diagnosis of multiple myeloma, planned combination with filgrastim (or biosimilar/tbo‑filgrastim), or intent for subsequent autologous transplant.

Step Therapy

Step Therapy / Sequencing

Step therapy and sequencing align with NCCN recommendations: Aphexda must be used in combination with filgrastim (or biosimilar) or tbo‑filgrastim for mobilization in multiple myeloma.

Follow NCCN guidance: Aphexda + filgrastim (or biosimilar) or tbo‑filgrastim for autologous donor mobilization.
Do not substitute for allogeneic donor mobilization regimens.

Covered Regimens and Indications

Regimen	Indication	Combination	Coverage status	Notes / limitations
Aphexda (motixafortide)	Stem cell mobilization for autologous hematopoietic stem cell transplant in multiple myeloma	In combination with filgrastim, filgrastim biosimilar, or tbo-filgrastim	Covered with criteria	Approval limited to one treatment cycle (includes up to two Aphexda injections: one dose prior to first apheresis and one dose prior to third apheresis). Not approved for >1 cycle, for allogeneic donors, or to mobilize leukemic cells.

Line of Therapy / Salvage

salvage

Positioning for salvage-line use:

Salvage

Use for autologous hematopoietic stem cell mobilization prior to autologous transplantation in multiple myeloma.

Definitions

inv-13: Definition of Aphexda (motixafortide)

Generic nameMotixafortide

Brand nameAphexda

Mechanism of actionChemokine receptor type 4 (CXCR4) inhibitor that disrupts retention of hematopoietic stem cells in the bone marrow microenvironment

Indication in policyUsed in combination with filgrastim (or biosimilar/tbo-filgrastim) to mobilize hematopoietic stem cells to peripheral blood for autologous transplantation in multiple myeloma

Guideline supportNCCN recommends use with filgrastim (or biosimilar) or tbo-filgrastim as a mobilization regimen for autologous transplantation in multiple myeloma

Background

Aphexda (motixafortide) is a selective CXCR4 antagonist that disrupts retention of hematopoietic stem cells in the bone marrow, enabling their mobilization into peripheral blood for collection. In this policy Aphexda is described and authorized specifically for use in combination with filgrastim, a filgrastim biosimilar, or tbo-filgrastim to mobilize autologous hematopoietic stem cells in individuals with multiple myeloma, with an intended subsequent autologous transplant. The approved regimen is limited to a single treatment cycle and a total of ≤ 2 doses (one dose prior to first apheresis and one dose prior to third apheresis).