Does Q2042 require prior authorization?

Yes, Q2042 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q2042?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`Q2042`, Tisagenlecleucel, up to 600 million car-positive viable t cells, including

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Procedure codes listed are for general reference and may not be all-inclusive.
Benefit coverage/reimbursement determinations must be based on the written coverage position in the Medical Policy, not on the presence or absence of listed codes.

Key Coverage Criteria

Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
Oncology medications are medically necessary if (a) the drug is FDA-approved for the oncologic indication and used per FDA labeling, OR (b) the drug has an NCCN Category 1/2A/2B indication per NCCN Guidelines or NCCN Compendium.
Oncology medications may be considered medically necessary when the drug (a) is FDA-approved for an oncologic indication and used per FDA labeling, or (b) has NCCN Category 1/2A/2B recommendation per NCCN Guidelines or NCCN Compendium.

20 Active Policies

ARKBLUE-TISAGENLECLEUCEL-E-G-KYMRIAH-E350B97BC4, Tisagenlecleucel (e.g., Kymriah)

MGBHP-KYMRIAH-23C80C875B, Kymriah

FALLON-MEDICAL-POLICY-KYMRIAH, Kymriah (tisagenlecleucel)

BCBSM-2089168-C14088D8F6, KYMRIAH (TISAGENLECLEUCEL)

POINT32HEALTH-MDMNG-13091, Kymriah (tisagenlecleucel)

MULTI

POINT32HEALTH-MDMNG-13081, Kymriah (tisagenlecleucel)

MULTI

BCBSNJ-DRUGS-158-DD09970816, Tisagenlecleucel (Kymriah)

METROPLUS-UM-MP219, UM-MP219 Kymriah (tisagenlecleucel)

MODA-KYMRIAH-B0F691E573, Kymriah (tisagenlecleucel)

HEALTHNET_OR-HNOR-TISAGENLECLEUCEL-KYMRIAH-CP-PHAR-361-6E51579F5C, Tisagenlecleucel (Kymriah); CP.PHAR.361

IBX-COMMERCIAL-08-01-43Q-95F094BB2B, Chimeric Antigen Receptor (CART) Therapy: Yescarta Tecartus, Breyanzi, Kymriah and Aucatzyl

IBX-MEDICARE-ADVANTAGE-MA08-093Q-068275F3C6, Chimeric Antigen Receptor (CART) Therapy: Yescarta Tecartus, Breyanzi, Kymriah and Aucatzyl

BCBSOK-RX502.061, Oncology Medications

AMERIHEALTH-COMMERCIAL-08-01-43Q-E26BE4F282, Chimeric Antigen Receptor (CART) Therapy: Yescarta Tecartus, Breyanzi, Kymriah and Aucatzyl

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-093Q-9957496496, Chimeric Antigen Receptor (CART) Therapy: Yescarta Tecartus, Breyanzi, Kymriah and Aucatzyl

BCBSTN-e03ec47248, Tisagenlecleucel (Kymriah)

OSCAR-KYMRIAH-TISAGENLECLEUCEL-CG058-VER-9-4F68D23327, Kymriah (tisagenlecleucel) (CG058, Ver. 9)

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

BCBSNM-RX502.061, Oncology Medications

`Q2042`, Tisagenlecleucel, up to 600 million car-positive viable t cells, including

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

Q2042, Tisagenlecleucel, up to 600 million car-positive viable t cells, including

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`Q2042`, Tisagenlecleucel, up to 600 million car-positive viable t cells, including