941 Form

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for CAR T-Cell Therapy Services for Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel) 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 Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel) Prior Authorization Request Form #941 Medical Policy #066 Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma

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 Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel) (941) 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 c or is REFRACTORYc : Histologically confirmed diagnosis of: Diffuse large B-cell lymphoma not otherwise specified (including diffuse large B-cell lymphoma arising from indolent lymphoma)  High-grade B-cell lymphoma, OR  Primary mediastinal large B-cell lymphoma, OR  Follicular lymphoma grade 3B. 

c Relapsed or refractory disease is defined as progression after 2 or more lines of systemic therapy (which may or may not include therapy supported by autologous cell transplant).

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

1. Histologically confirmed diagnosis of large B-cell lymphoma, including diffuse large B-cell lymphoma not otherwise specified (including diffuse large B-cell lymphoma arising from indolent lymphoma), high-grade B- cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B; AND 

2. Meets at least one of the following: a. Primary refractory or relapsed diseasec within 12 months of first-line chemo-immunotherapy that included an anti-CD20 monoclonal antibody and anthracycline-containing regimen; OR b. Primary refractory or relapsed disease within 12 months of first-line chemo-immunotherapy that included an anti-CD20 monoclonal antibody and anthracycline-containing regimen and are not eligible for hematopoietic stem cell transplantation due to comorbidities or age; OR c. Relapsed or refractory disease as defined as progression after ≥2 lines of systemic therapy including anti-CD20 monoclonal antibody for CD20-positive tumor and anthracycline-containing chemotherapy i. When the individual has histological transformation of follicular lymphoma or marginal zone lymphoma to diffuse large B-cell lymphoma: prior chemotherapy for follicular lymphoma or marginal zone lymphoma and ≥2 chemo-immunotherapy regimens for the transformed disease; 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 gene therapy or are being considered for treatment with any other cell therapy or any gene therapy; AND

   

6. Do not have primary central nervous system lymphoma.

   

   c Relapsed or refractory disease is defined as progression after 2 or more lines of systemic therapy (which may or may not include therapy supported by autologous cell transplant).

   CPT CODES/ HCPCS CODES/ ICD CODES

   HCPCS codes: Code Description C9076 Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose  C9399 Unclassified drugs or biologicals  J3490 Unclassified drugs  J3590 Unclassified biologics 

J9999 Not otherwise classified, antineoplastic drugs 

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

Code Description  

Providers should enter other relevant code(s) below:

Code Description  

• 2 -