209 Form

Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency – Kebilidi Prior Authorization Request Form #209

Medical Policy #180 Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency - Kebilidi

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 Gene Therapy for Aromatic L-amino Acid Decarboxylase Deficiency (209) 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  Distributor: Accredo Specialty Pharmacy 

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

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for Kebilidi 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.

Please check off if the patient has the following diagnosis: Aromatic L-amino acid decarboxylase (AADC) deficiency 

Please check off that the patient meets ALL the following criteria: Diagnostic criteria for aromatic L-amino acid decarboxylase (AADC) deficiency:

1. Biallelic pathogenic/likely pathogenic variants in dopa decarboxylase (DDC) gene
   
2. One pathogenic/likely pathogenic variant plus a variant of uncertain significance AND aromatic L-amino acid decarboxylase enzyme activity in plasma < 5% OR cerebrospinal fluid or plasma neurotransmitter profile consistent with aromatic L-amino acid decarboxylase deficiency
   

3. Two variants of uncertain significance AND aromatic L-amino acid decarboxylase enzyme activity in plasma < 5% OR cerebrospinal fluid or plasma neurotransmitter profile consistent with aromatic L- amino acid decarboxylase deficiency  Has persistent neurological defects (e.g., autonomic dysfunction, hypotonia, dystonia and other movement disorders, etc.)  Has anti-AAV2 antibody titer <1:1,200  Achieved skull maturity assessed by neuroimaging  Medication is being administered at United States Food and Drug Administration approved dosing by a
   healthcare professional  Medication is planned to be administered in a medical center which specializes in stereotactic neurosurgery. 

   CONTRAINDICATIONS

   Please check off that the patient DOES NOT HAVE ANY of the following contraindications: • Pregnancy.  • Breastfeeding.  • Presence of significant medical or neurological conditions that would create an unacceptable operative or anesthetic risk (e.g. patient has not achieved skull maturity). 

   HCPCS Codes Code Description C9399 Unclassified drugs or biological J3590 Unclassified biologics

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

   Code Description  

   Providers should enter other relevant code(s) below:

   Code Description  

• 2 -