Billing Instructions for Cell and Gene Therapy (CGT) Access Model
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Guidance on billing and reimbursement for CMS CGT Access Model drugs (Casgevy and Lyfgenia) for West Virginia Medicaid, including prior authorization, POS billing, and reimbursement methodology effective January 1, 2026.
No material clinical or coverage changes in this revision.
Coverage and Eligibility
Coverage and billing criteria
CGT Model Drugs are eligible for reimbursement when qualifying eligibility criteria are met and prior authorization is obtained.
ALL of the following
- Prior authorization required prior to treatment
See Prior Authorization Criteria page for CGT Model Drug criteria.
- Model Drugs must be billed as Point of Sale (POS) claims with NDC and units dispensed
Submission of the NDC and units dispensed is required on POS claims.
- Casgevy (exagamglogene autotemcel) and Lyfgenia (lovotibeglogene autotemcel) are reimbursed at actual acquisition cost pharmacy reimbursement methodology and paid outside of hospital reimbursement methodology per State Plan Amendment WV 25-0006
Model Drugs approved under the model will be reimbursed separately from inpatient DRG payments.
- Hospitals are eligible for reimbursement for the CGT Model Drug in addition to the Diagnosis Related Group (DRG) for the inpatient admission
Other services related to CGT provided to an admitted patient continue to be billed on the inpatient hospital claim.
Billing Codes and Requirements
| NDC required | Submission of the NDC and units dispensed is required when billing CGT Model Drugs as POS claims. |
| POS | Point of Sale billing methodology for the CGT Model Drugs. |
Required Provider Actions
Obtain prior authorization before CGT treatment
Prior authorization must be obtained before providing CGT treatment for sickle cell disease to West Virginia Medicaid members. Providers should visit the Prior Authorization Criteria page for the CGT Model Drug criteria and secure approval prior to administration or dispensing.
- Requirement applies to Casgevy and Lyfgenia under the CGT Access Model.
- CGT Model Drugs are eligible for reimbursement only when qualifying eligibility criteria are met and prior authorization is obtained.
Key Definitions
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