CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Kymriah Request Form

A payer-specific prior authorization (PA) request form to collect member, provider, clinical, and billing information for Kymriah (intravenous tisagenlecleucel) infusion requests. It captures indication, required documentation (e.g., CD19 expression), prior therapies, J/CPT codes and units requested, and signature attestation.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyKymriah Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and sign the Kymriah prior authorization form in its entirety and submit requested clinical documentation to the Pharmacy Dept via fax 1-844-639-7906 or phone 1-401-427-8200.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

3Major indication groups listed

multipleRequired documentation items (checkboxes)

Policy overview

This is a payer-specific prior authorization form from Neighborhood Health Plan of Rhode Island for intravenous tisagenlecleucel (Kymriah). The form is used to request coverage/authorization and collects member, provider, clinical, and billing information (including indication, CD19 expression, prior therapies, J/CPT codes and units, dates of service, and physician signature). Authorization decisions will reference the plan's clinical medical policies and are subject to benefit coverage and member eligibility.

Key metadata

PayerNeighborhood Health Plan of Rhode Island

PolicyKymriah (tisagenlecleucel) prior authorization request form

Policy NumberN/A

StatusCURRENT

Effective Date

Last Review / Next Review

ScopeA payer-specific prior authorization (PA) request form to collect member, provider, clinical, and billing information for Kymriah (intravenous tisagenlecleucel) infusion requests. It captures indication, required documentation (e.g., CD19 expression), prior therapies, J/CPT codes and units requested, and signature attestation.

Coverage intent & clinical criteria

Clinical information fields (checkbox items to support PA review)

Complete all applicable items and submit documentation; checkboxes represent potential coverage criteria elements to be verified by clinical review.

Documentation required for ALL

Indication selection
- Member has diagnosis of Acute Lymphoblastic Leukemia (ALL)
- Member has diagnosis of B-Cell Lymphomas
Prior Kymriah/Yescarta status or SCT/relapse criteria
- Member has confirmed documentation of CD19 tumor expression (demonstrated in bone marrow or peripheral blood by flow cytometry)
- Member has not previously experienced treatment failure on Kymriah® or Yescarta®
- Member has experienced disease relapse after allogeneic stem cell transplantation (SCT) and member is ≥ 6 months from above transplantation at the time of infusion
- Member has relapsed/refractory Philadelphia chromosome -negative B-ALL that has progressed after 2 cycles of a standard chemotherapy regimen for initial diagnosis OR after 1 cycle of standard chemotherapy for relapsed leukemia
- Member has relapsed/refractory Philadelphia chromosome -positive B-ALL that has progressed after failure of 2 TKI-containing regimens

Documentation required for B‑Cell Lymphomas

The member has grade 1-2 relapsed or refractory follicular lymphoma or relapsed/refractory DLBCL - Diffuse Large B-Cell Lymphoma
Member has experienced disease progression after two or more lines of systemic therapy (if Kymriah® or Yescarta® not previously given)

Requested billing codes

Requested J-Code(s) for entire treatment regimenHCPCS

No codes listed

Requested CPT code(s)CPT

No codes listed

Diagnosis codes to be providedICD-10

No codes listed

Include the requested J-code(s), CPT code(s), directions, number of units requested, and dates of service on the form to support authorization and subsequent claim processing.

Required provider actions

Prior Authorization

Submit completed PA form

Providers must complete and sign this Kymriah prior authorization form in its entirety and submit requested clinical documentation (e.g., CD19 expression, prior therapy history) to the Pharmacy Dept via fax to 1-844-639-7906 or phone 1-401-427-8200; incomplete forms may delay review.

Fax: 1-844-639-7906
Phone: 1-401-427-8200

Documentation Required

Clinical documentation for indications and prior therapies

Provide documentation of diagnosis, CD19 tumor expression (flow cytometry results), prior lines of systemic therapy, stem cell transplant dates, and prior CAR-T exposure status to support clinical review.

CD19 expression (demonstrated in bone marrow or peripheral blood by flow cytometry)
Prior therapy history / prior lines of systemic therapy
Stem cell transplant dates (including date(s) of allogeneic SCT)
Prior CAR‑T exposure (e.g., prior Kymriah® or Yescarta® status)

Billing Rule

Provide requested billing codes and units

Include requested J-code(s), CPT code(s), directions, number of units requested, and dates of service for the entire treatment regimen on the form to support authorization and subsequent claim processing.

Requested J-code(s) for the entire treatment regimen
Requested CPT code(s)
Directions
Number of units requested
Dates of service

Documentation Required

Physician signature required

The form must be signed by a physician; unsigned forms are not complete and may delay authorization.

Background

This payer-specific prior authorization form requests coverage/authorization for intravenous Kymriah (tisagenlecleucel), references clinical policy review, and requires submission of supporting documentation (for example, CD19 tumor expression, prior therapy history, and transplant dates). The form notes that completion and physician signature are required and that any authorization is not a guarantee of reimbursement and remains subject to plan benefit coverage, member eligibility, and other payment rules.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyKymriah Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Kymriah Request Form

Policy overview

Document changes

Coverage intent & clinical criteria

Requested billing codes

Required provider actions

Background

Revision history