217 Form

Gene Therapies for Thalassemia – Prior Authorization Request Form for Casgevy™ (Exagamglogene autotemcel), #217

Medical Policy #215 Gene Therapies for Thalassemia

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

Physician Information Facility Information Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI#:

Please check off if the patient has the following diagnosis: Sickle Cell Disease 

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

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  1. Documented diagnosis of β-thalassemia (e.g., β-thalassemia major and thalassemia intermedia) by globin gene testing; AND

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  2. Require regular peripheral blood transfusions to maintain target hemoglobin levels as defined by the following: a. History of receiving transfusions of ≥100 mL per kilogram of body weight of packed red blood cells per year; OR b. History of receiving ≥8 transfusions per year in the previous 2 years at the time of treatment decision; AND

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  3. Meet the institutional requirements for a stem cell transplant procedure where the individual is expected to receive gene therapy. These requirements may include: i. Adequate Karnofsky performance status or Lansky performance status ii. Absence of advanced liver disease iii. Adequate estimated glomerular filtration rate (eGFR) iv. Adequate left ventricular ejection fraction (LVEF) v. Absence of clinically significant active infection(s); AND

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  4. Have not had a T2*-weighted magnetic resonance imaging measurement of myocardial iron of less than 10 msec or other evidence of severe iron overload in the opinion of treating physician); AND

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  5. Have not received a previous allogenic hematopoietic stem cell transplant; AND

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  6. Do not have a current application pending for another gene therapy for beta thalassemia.

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  HCPCS Codes Code Description C9399 Unclassified drugs or biologicals J3392 Injection, exagamglogene autotemcel, per treatment J3490 Unclassified drugs J3590 Unclassified biologics

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

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  Providers should enter other relevant code(s) below: Code Description

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