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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyDC Medicaid Inpatient CGT Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

    Clarification to Transmittal 25-12, Inpatient Reimbursement for Physician-Administered Cell and Gene Therapy

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    Governs coverage, prior authorization, billing, and reimbursement for approved inpatient cell and gene therapy medications for eligible DC Medicaid beneficiaries, including separate medication reimbursement and managed care claim responsibilities.

    Policy Summary
    PayerDistrict of Columbia Department of Health Care Finance
    PolicyClarification to Transmittal 25-12, Inpatient Reimbursement for Physician-Administered Cell and Gene Therapy
    Policy CodePolicy N/A
    Change TypeClarification
    Effective DateJanuary 28, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization before administering any inpatient cell and gene therapy service.
    SourceLink
    POLICY UPDATE CHANGES

    Approved inpatient cell and gene therapy medication costs are carved out of the DRG bundled payment and reimbursed separately through DHCF Fee-for-Service Medicaid.

    Medicaid Managed Care Plans remain responsible for CGT-related services other than medication costs for beneficiaries enrolled in managed care.

    Lyfgenia and Casgevy are identified as covered inpatient cell and gene therapies subject to clinical criteria and prior authorization.

    2FDA-approved CGT products specifically identified

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    12+ years
    Minimum age for listed therapies
    J3392 / J9934Assigned HCPCS codes
    PA requiredCovered CGT therapy requirement
    Prohibited340B-purchased products
    FFS onlyMedication reimbursement responsibility

    Covered Inpatient Cell and Gene Therapies

    Covered Inpatient Cell and Gene Therapies

    DHCF Medicaid covers the following inpatient cell and gene therapy (CGT) medications when the applicable coverage criteria are met. Therapies must be administered exclusively at inpatient facilities that are qualified treatment centers.

    ALL of the following

    • ONE of the covered therapies and indications

      • Lyfgenia (lovotibeglogene autotemcel)

        • Patient is 12 years of age or older.
        • Patient has sickle cell disease with a history of vaso-occlusive events.

      • Casgevy (exagamglogene autotemcel)

        • Patient is 12 years of age or older.

        • ONE of the following indications

          • Sickle cell disease (SCD) with recurrent vaso-occlusive crises (VOCs).
          • Transfusion-dependent beta-thalassemia (TDT).
    • The medication is administered exclusively at an inpatient facility that is a qualified treatment center.
    • Prior authorization is obtained before administering inpatient CGT services. All therapies in the CGT class currently require prior authorization.

      Submit the prior authorization request to DHCF's designated agent, Comagine Health, through the provider portal: https://comagine.org/program/dc-medicaid-um. Questions may be directed to Comagine Health at 1-800-251-8890.

    • The provider submits the required clinical documentation, including diagnosis confirmation, the patient's history of prior treatment failures, justification for the therapy, and other relevant and necessary clinical documentation.

      DHCF's clinical criteria for the CGT class are available at https://www.dc-pbm.com/provider/landing.

    Therapy Coding and Indications

    Assigned HCPCS codes for covered inpatient CGT medicationsHCPCSCovered
    J3392Casgevy (exagamglogene autotemcel)
    J9934Lyfgenia (lovotibeglogene autotemcel)
    Required product identificationNDCCovered
    NDCNational Drug Code corresponding to the administered therapy label; the NDC on the claim must correspond to the NDC on the administered therapy label.
    Interim coding for newly approved therapiesHCPCS
    Unclassified HCPCSUse when CPT or HCPCS procedure codes are unavailable for a newly approved cell and gene therapy, until a specific product code has been assigned.
    Minimum patient age
    Minimum age12 years and older
    Covered therapiesLyfgenia and Casgevy
    Administration settingInpatient facility that is a qualified treatment center
    Lyfgenia indication
    TherapyLyfgenia
    Generic nameLovotibeglogene autotemcel
    Indication

    Authorization, Documentation, and Billing Requirements

    Prior Authorization

    Obtain prior authorization

    Obtain prior authorization before administering any inpatient cell and gene therapy service. Submit the request to DHCF’s designated agent, Comagine Health, through the Comagine provider portal.

    Documentation Required

    Submit clinical documentation

    Include the required clinical documentation with the prior authorization request to support the patient’s eligibility and medical necessity.

    • Diagnosis confirmation
    • Patient history of prior treatment failures
    • Justification for the therapy
    • Other relevant and necessary clinical documentation

    Policy Terms and Responsibilities

    CGT
    TermCGT
    DescriptionHigh-cost inpatient cell and gene therapies
    Coverage basisCovered under specified DHCF Medicaid protocols when clinically indicated
    Medication carve-out
    Medication componentApproved inpatient CGT medication costs
    Payment treatmentRemoved from the Diagnosis Related Treatment Group (DRG) bundled payment methodology
    Separate reimbursementReimbursed through the DHCF Fee-for-Service Medicaid program
    Policy Summary
    PayerDistrict of Columbia Department of Health Care Finance
    PolicyClarification to Transmittal 25-12, Inpatient Reimbursement for Physician-Administered Cell and Gene Therapy
    Policy CodePolicy N/A
    Change TypeClarification
    Effective DateJanuary 28, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization before administering any inpatient cell and gene therapy service.
    SourceLink
    On This Page
    Covered Inpatient Cell and Gene TherapiesTherapy Coding and IndicationsAuthorization, Documentation, and Billing RequirementsPolicy Terms and Responsibilities
    Sickle cell disease with a history of vaso-occlusive events
    Casgevy sickle cell indication
    TherapyCasgevy
    Generic nameExagamglogene autotemcel
    IndicationSickle cell disease with recurrent vaso-occlusive crises
    Casgevy beta-thalassemia indication
    TherapyCasgevy
    Generic nameExagamglogene autotemcel
    IndicationTransfusion-dependent beta-thalassemia
    Billing Rule

    Bill the CGT medication separately

    Submit a separate claim for the inpatient CGT medication to DHCF Fee-for-Service Medicaid using a CMS-1500, the appropriate HCPCS code, and the applicable NDC. The NDC on the claim must correspond to the NDC on the administered therapy label.

    • Casgevy: J3392
    • Lyfgenia: J9934
    Denial Risk

    Do not use 340B-purchased products

    Do not dispense 340B-purchased Casgevy or Lyfgenia drug products.

    Billing Rule

    Route claims according to enrollment

    For Medicaid Managed Care beneficiaries, submit claims for drug administration, inpatient hospital services, and other supportive care directly to the beneficiary’s Medicaid Managed Care Plan. Submit only the CGT medication claim to Fee-for-Service Medicaid.

    • Drug administration
    • Inpatient hospital services
    • Other supportive care
    Billing Rule

    Use unclassified coding when necessary

    Use an unclassified HCPCS code for a newly approved CGT when a specific CPT or HCPCS code is unavailable. Continue using the unclassified code until a product-specific code is assigned.

    MCP responsibility
    Managed care responsibilityMedicaid Managed Care Plans remain responsible for CGT-related healthcare services other than the medication cost
    ExamplesDrug administration, hospital inpatient stays, and other supportive care
    Fee-for-Service responsibilityFFS Medicaid is responsible for reimbursement of the CGT medication to the billing provider