Lyfgenia (lovotibeglogene autotemcel) prior authorization form and requirements
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Prior authorization form and requirements for Lyfgenia (lovotibeglogene autotemcel) for Geisinger Health Plan members; directed to prescribers and service providers submitting requests for this gene therapy.
No material clinical or coverage changes in this revision.
Coverage Criteria — Eligibility and Exclusions
Initial therapy / eligibility
Covered when ALL of the following are met (checkboxes on the form must be selected and documentation submitted):
Each item corresponds to a required checkbox on the form.
Form requires documentation of the event(s) and associated clinical records (e.g., ED or hospital visits) as applicable.
The checklist on the prior authorization form includes an explicit exclusion: the patient must not have received a prior allogeneic hematopoietic stem cell transplant. The form provides a checkbox for the prescriber to confirm this; if that box is not checked (indicating a prior allogeneic transplant), the request does not meet this coverage criterion and should be handled as excluded per the form.
Requested Billing Codes
| HCPCS code (required) | Form requests HCPCS code for the drug/infusion (exact code to be provided by requester) |
| DX code (required) | Diagnosis code field required on the form |
| HCPCS code (required) | HCPCS code field required on the form |
Prior Authorization, Documentation, and Submission Instructions
Prior authorization submission required
Prior authorization must be submitted either online through PromptPA or by faxing the completed prior authorization form and required clinical documentation to Geisinger Health Plan.
- Online submission: https://ghp.promptpa.com (PromptPA)
- Fax submission: 570-271-5610 — include the completed Lyfgenia prior authorization form and all supporting documentation
No step therapy listed
No step therapy or sequencing requirements are specified on the Lyfgenia prior authorization form.
Documentation required with PA form
Include the completed Lyfgenia prior authorization form plus relevant clinical documentation demonstrating eligibility.
- Recent chart/clinic notes
- Diagnostic evaluations and test results (including confirmatory genetic testing for sickle cell disease)
- Documentation of vaso-occlusive episode history (e.g., ED or hospital visits) or records showing current chronic transfusion therapy, as applicable
- Completed form fields: diagnosis, DX code, and HCPCS code (HCPCS code entry is required on the form)
Incomplete or missing documentation may cause denial
Failure to submit the completed form or the required supporting documentation may result in denial or delay of the prior authorization request.
- Missing required items on the form (e.g., diagnosis, DX code, HCPCS code) can trigger denial
- Incomplete clinical documentation (chart notes, diagnostic tests, genetic confirmation, or transfusion history) may cause processing delays or denial
Therapy Background
Lyfgenia (lovotibeglogene autotemcel) is a gene therapy for sickle cell disease. The prior authorization form is intended to document patient eligibility for treatment and to collect required clinical support. Key items requested on the form include confirmation that the patient is clinically stable for transplantation per the prescriber, confirmation that the patient has not had a prior allogeneic hematopoietic stem cell transplant, and documentation of confirmatory genetic testing for sickle cell disease. The form also requires evidence of disease complications, defined as at least one of: a history of vaso‑occlusive episodes requiring a medical facility visit (for example pain crises, acute chest syndrome, splenic sequestration, or priapism) or current receipt of chronic transfusion therapy for recurrent vaso‑occlusive episodes. Submit the completed form and supporting documentation via PromptPA (https://ghp.promptpa.com) or fax to 570-271-5610.
Key Definitions and Clinical Terms
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