940 Form

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for CAR T-Cell Therapy Services for Mantle Cell Lymphoma (Brexucabtagene Autoleucel) must be submitted. ▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

CAR T-Cell Therapy Services for Mantle Cell Lymphoma (Brexucabtagene Autoleucel) Prior Authorization Request Form #940 Medical Policy #066 Chimeric Antigen Receptor Therapy for Hematologic Malignancies

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for CAR T-Cell Therapy Services for Mantle Cell Lymphoma (Brexucabtagene Autoleucel) (940) using Authorization Manager.

For out of network providers: Requests should still be faxed to 888-973-0726.

Patient Information Patient Name: Today’s Date: BCBSMA ID#: Date of Treatment: Date of Birth: Place of Service: Outpatient  Inpatient 

Physician Information Facility Information Name: Name: Address: Address: Phone #: Phone #: Fax#: Fax#: NPI#: NPI#:

Clinical Trial # 

Please check off if the patient has the following diagnosis and HAS RELAPSED d or is REFRACTORYd : Histologically confirmed diagnosis of mantle cell lymphoma 

d Relapsed or refractory disease is defined as disease progression after last regimen or failure to achieve a partial remission or complete remission to the last regimen

Please check off that the patient meets ALL the following criteria:

1. Histologically confirmed diagnosis of relapsed or refractoryd mantle cell lymphoma; AND 
2. Received adequate prior therapy including anthracycline- or bendamustine-containing chemotherapy, anti-CD20 monoclonal antibody, and a Bruton tyrosine kinase inhibitor (ie, acalabrutinib, ibrutinib, zanubrutinib); AND 
3. At least 18 years of age at the time of infusion; AND 
4. Have adequate organ and bone marrow function as determined by the treating oncologist/hematologist; AND 

5. Have not received prior CD19-directed chimeric antigen receptor T-cell therapy treatment, any other cell therapy, or any other gene therapy or are being considered for treatment with any other cell therapy or any gene therapy.  d Relapsed or refractory disease is defined as disease progression after last regimen or failure to achieve a partial remission or complete remission to the last regimen.

   CPT CODES/ HCPCS CODES/ ICD CODES

   HCPCS codes: Code Description C9399 Unclassified drugs or biologicals

   J3490 Unclassified drugs

   J3590 Unclassified biologics

   J9999 Not otherwise classified, antineoplastic drugs

   Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

   XW23346 Transfusion of Brexucabtagene Autoleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 6

   Providers should enter the relevant diagnosis code(s) below:

   Code Description

   Providers should enter other relevant code(s) below:

   Code Description

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