222 Form

Engineered T-Cell Therapy for Synovial Sarcoma (Tecelra®)– Prior Authorization Request Form, #222

Medical Policy #213 Engineered T-Cell Therapy for Synovial Sarcoma (Tecelra®)

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 Engineered T-Cell Therapy for Synovial Sarcoma (Tecelra®) (213) 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:

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 engineered T-cell therapy for unresectable or metastatic synovial sarcoma (afamitresgene 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

Please check off if the patient is enrolled in a Clinical Trial: Clinical Trial # 

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

1. At least 18 years of age; AND 
   2. Have a diagnosis of synovial sarcoma that is either: a. Unresectable OR b. Metastatic OR c. Refractory to most recent treatment OR
      d. Progressed after most recent treatment 
2. Member’ tissues and cells express one of the following HLA markers; AND -A02:01P  -A02:02P  -A02:03P  -A02:06P 
3. Tumor expresses the MAGE-A4 antigen as determined by FDA-approved or cleared Companion Diagnostic; AND 
4. ECOG performance scale of 0 or 1; AND 
5. No history of CNS metastases; AND 
6. No active or serious infections; AND 
7. Cardiac ejection fractions ≥ 50%; AND 

8. No prior treatment with any engineered autologous T-cell product directed at any target (including any CAR-T or tumor-infiltrating lymphocytes) 

   CPT CODES/ HCPCS CODES/ ICD CODES

   HCPCS codes: Code Description Q2057 Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose (Tecelra)  C9399 Unclassified drug or biologic  J3590 Unclassified biologic  J3490 Unclassified drugs  J9999 Not otherwise classified, antineoplastic 

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

   Code Description  

   Providers should enter other relevant code(s) below:

   Code Description   