00146
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- A one-time infusion of betibeglogene autotemcel is consideredmedically necessaryin individuals whenallof the following criteria are met:
- Diagnosis of beta thalassemia;and
- Transfusion-dependent disease (that is, needing at least 8 transfusions or at least 100 ml per kilogram of body weight of packed red cells per year in the previous 2 years);and
- The individual is a candidate for an allogeneic hematopoietic cell transplantation, but ineligible due the absence of a donor*;and
- Has no evidence of severe iron overload (for example, T2*-weighted magnetic resonance imaging [MRI] measurements of myocardial iron greater than 10 msec);and
- No serious concomitant illness (for example, advanced liver disease, uncorrected bleeding disorder, current malignancy, myeloproliferative and/or immunodeficiency disorder, uncontrolled seizure disorder).
2 Active Policies
ANTHEM-MED.00140 — MED.00140 Gene Therapy for Beta Thalassemia
ANTHEM-MED.00146 — MED.00146 Gene Therapy for Sickle Cell Disease
Related Codes
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