CurrentBlue Cross Blue Shield - MassachusettsPolicy Medical Policy #066

CAR T-Cell Therapy Services for Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel) Prior Authorization Request Form #941

Prior authorization request form and medical necessity checklist for CAR T-Cell Therapy (lisocabtagene maraleucel) for specified large B-cell non-Hodgkin lymphoma subtypes. Specifies clinical eligibility criteria, required documentation, submission instructions, and billing/coding guidance for HCPCS/CPT/J-codes related to CAR T services.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCAR T-Cell Therapy Services for Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel) Prior Authorization Request Form #941

Policy CodePolicy Medical Policy #066

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit initial authorization requests and complete the CAR T-Cell Therapy Services Prior Authorization Request Form (941) using Authorization Manager; for out-of-network requests, fax to 888-973-0726.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

4Listed eligible lymphoma subtypes

>=18Minimum patient age (years)

2+Required prior systemic therapy lines

Coverage Summary

Blue Cross Blue Shield - Massachusetts — Prior authorization checklist/form for lisocabtagene maraleucel (CAR T) for specified large B-cell non-Hodgkin lymphoma subtypes (Medical Policy #066). This is a prior authorization request form and medical necessity checklist for CAR T-Cell Therapy (lisocabtagene maraleucel) for specified large B-cell non-Hodgkin lymphoma subtypes, including Diffuse large B-cell lymphoma 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.

Coverage stance: Covered with criteria. Eligibility requires the patient to be at least 18 years of age at infusion and to have relapsed or refractory disease defined as progression after 2 or more lines of systemic therapy. The form specifies clinical eligibility criteria, required documentation, submission instructions, and billing/coding guidance (HCPCS/CPT/J-codes) to support medical necessity determinations.

Listed eligible lymphoma subtypes4

Minimum patient age (years)>=18

Required prior systemic therapy lines for relapsed/refractory definition2+

Medical-Necessity Criteria (Eligibility)

Eligibility / Medical Necessity Criteria

Covered when ALL of the following are met:

ALL of the following

ONE of
- Diffuse large B-cell lymphoma not otherwise specified (including DLBCL arising from indolent lymphoma)
- High-grade B-cell lymphoma
- Primary mediastinal large B-cell lymphoma
- Follicular lymphoma grade 3B
Relapsed or refractory disease defined as progression after 2 or more lines of systemic therapy (which may or may not include therapy supported by autologous cell transplant).
ANY of the following
- Primary refractory or relapsed disease within 12 months of first-line chemo-immunotherapy that included an anti-CD20 monoclonal antibody and an anthracycline-containing regimen.
- Primary refractory or relapsed disease within 12 months of first-line chemo-immunotherapy that included an anti-CD20 monoclonal antibody and an anthracycline-containing regimen AND not eligible for hematopoietic stem cell transplantation due to comorbidities or age.
- Relapsed or refractory disease as defined as progression after 2 or more lines of systemic therapy including anti-CD20 monoclonal antibody for CD20-positive tumor and anthracycline-containing chemotherapy.
- When histologic transformation of follicular lymphoma or marginal zone lymphoma to DLBCL has occurred: prior chemotherapy for the indolent lymphoma and 2 or more chemo-immunotherapy regimens for the transformed disease.
Age requirement: At least 18 years of age at the time of infusion.
Have adequate organ and bone marrow function as determined by the treating oncologist/hematologist.
No prior CD19-directed chimeric antigen receptor T-cell therapy, no prior other cell therapy, and no prior gene therapy; not currently being considered for any other cell or gene therapy.

Coding (Form-listed codes)

HCPCS / Billing codes listed on formHCPCS

C9076	Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
C9399	Unclassified drugs or biologicals
J3490	Unclassified drugs
J3590	Unclassified biologics
J9999	Not otherwise classified, antineoplastic drugs

Provider-entered diagnosis / other codesICD-10

No codes listed

Billing Rule

Billing / Coding Guidance

The form lists HCPCS / billing codes for lisocabtagene maraleucel and related unclassified drug/biologic codes. When submitting claims or prior authorization requests, ensure accurate provider and facility identifiers are included so services are processed correctly.

Enter the servicing provider NPI or provider ID (surgeon/servicing provider).
Enter the facility NPI or provider ID where services are performed.

Provider Actions & Prior Authorization

Prior Authorization

Submit prior authorization via Authorization Manager

Submit initial authorization requests and complete the CAR T-Cell Therapy Services Prior Authorization Request Form (941) using Authorization Manager. Authorization Manager is available 24/7 and is the quickest method to request authorizations, submit clinical documentation, check case status, and view/print the decision letter.

Authorization Manager (online submission)
Fax for out-of-network requests: 888-973-0726

Documentation Required

Submit clinical documentation to support medical necessity

Submit clinical documentation that supports each of the medical necessity criteria on the form. If the patient does not meet all listed criteria, submit a letter of medical necessity requesting a Clinical Exception (Individual Consideration) that explains the rationale for the exception.

Include documentation that maps to each medical necessity criterion on the checklist.
If criteria are not met, include a detailed letter of medical necessity requesting individual consideration.

Documentation Required

Enter correct provider and facility identifiers

Include correct servicing provider and facility identifiers on the prior authorization request to ensure accurate and prompt processing.

Include servicing provider NPI or provider ID (surgeon/servicing provider).
Include facility NPI or provider ID where services are performed.

Background

This form and checklist accompany Medical Policy #066 (Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma) and are intended to collect patient, facility, and clinical documentation to determine medical necessity for lisocabtagene maraleucel (CAR T) in specified large B-cell lymphomas.

Relapsed or refractory disease: Progression after 2 or more lines of systemic therapy (which may or may not include therapy supported by autologous cell transplant).