067 Form

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Adjunct Medications to Support Hematopoietic Stem Cell Transplantation and its Complications Prior Authorization Request Form #067

Medical Policy #028 Adjunct Medications to Support Hematopoietic Stem Cell Transplantation and its Complications

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for Omisirge (Omidubicel-onlv) and Ryoncil (remestemcel-L-rknd) 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.

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 Omidubicel-onlv (Omisirge®) (067) 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:

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Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI#:

For Omisirge Requests: Criteria for initial approval for one-time infusion one treatment course per lifetime

Please check off if the patient has the following diagnosis: Hematologic malignancy 

Please check off if the patient meets ALL of the following conditions:
• Individual is 12 years of age and older AND

 • Individual has a diagnosis of hematologic malignancies who are planned for umbilical cord blood transplantation following myeloablative conditioning to reduce:
o time to neutrophil recovery AND o the incidence of infection.

 • Individual is candidate for myeloablative allogeneic hematopoietic stem cell transplantation (HSCT) AND

 • Individual does not have ANY of the following: o Availability of human leukocyte antigen-identical or human leukocyte antigen- matched donor or human leukocyte antigen-haploidentical donor o History of receiving prior allogenic hematopoietic stem cell transplant o Other malignancy or significant immunodeficiency disorder o Active, uncontrolled HCV or HBV infection AND

 • The medication is being prescribed by or in consultation with hematologist/oncologist.



For Ryoncil Requests:

Please check off if the patient has the following diagnosis: Steroid Refractory Acute Graft-versus-Host Disease (SR-aGvHD) 

Please check off if the patient meets ALL of the following conditions:
• Individual is 2 months of age and older AND

 • Individual has a diagnosis of steroid-refractory acute graft versus host disease (SR- aGvHD)  • Patient’s acute graft versus host disease (aGvHD) progressed within 3 days or did not improve within 7 consecutive days of treatment with either: 1) Methylprednisolone 2 mg/kg/day OR 2) Other corticosteroid equivalent

1)  2) 

CPT CODES/ HCPCS CODES/ ICD CODES

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HCPCS codes: Code Description C9399 Unclassified drugs or biologicals J3590 Unclassified biologics