Q2057, Afamitresgene autoleucel, including leukapheresis and dose preparation
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical record documentation confirming diagnosis of unresectable or metastatic synovial sarcoma.
- Clinical documentation supporting medical necessity for Tecelra in this patient (treatment rationale, prior therapies, disease status).
- Pathology confirming diagnosis of synovial sarcoma (inferred requirement to establish the covered indication).
- Documentation confirming disease is metastatic or inoperable (inferred requirement to meet the described indication).
Key Coverage Criteria
- Treatment of metastatic or inoperable synovial sarcoma (Tecelra proposed to address need for new treatments in individuals with metastatic or inoperable synovial sarcoma).
- Tumors that express Melanoma-associated antigen A4 (MAGE-A4) are the molecular target of Tecelra (implied indication: MAGE-A4–expressing tumors are potential targets for this TCR gene therapy).
- HLA-A*02:01P, -A*02:02P, -A*02:03P or -A*02:06P positive; AND
- Has received prior chemotherapy; AND
- Tecelra (afamitresgene autoleucel) is indicated for the treatment of adults with unresectable or metastatic synovial sarcoma who have previously received chemotherapy, are HLA-A*02:01, HLA-A*02:02, HLA-A*02:03 or HLA-A*02:06 positive, and whose tumors express the MAGE-A4 antigen.
- Tecelra (afamitresgene autoleucel), single dose will be considered medically reasonable and necessary when the following indications are met
5 Active Policies
HUMANA-TECELRA-AFAMITRESGENE-AUTOLEUCEL-MA, Tecelra (afamitresgene autoleucel)
BCBSIL-RX502.061, Oncology Medications
BCBSMT-RX502.061, Oncology Medications
BCBSNM-RX502.061, Oncology Medications
BCBSOK-RX502.061, Oncology Medications
Related Codes
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