MedicaidPrior AuthMedium impact
Benefit and Prior Authorization Information for Allogeneic Processed Thymus Tissue-agdc (Rethymic)
Texas Medicaid·TX · Pediatrics, Allergy & Immunology, Infectious Disease·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jul 30, 2026
Summary
Texas Medicaid now covers allogeneic processed thymus tissue-agdc (Rethymic) for pediatric patients with congenital athymia effective July 1, 2026, with mandatory prior authorization required beginning September 1, 2026. Billing teams must implement prior authorization workflows using SMPA forms and ensure claims are submitted with procedure code J3590. This is a specialized, rare procedure limited to one lifetime surgical procedure per eligible patient.
Action Required
By September 1, 2026: Billing team and providers must implement prior authorization workflow for Rethymic (J3590) claims. Specific actions: (1) Update billing system to flag J3590 claims for prior authorization requirement; (2) Establish process for submitting Special Medical Prior Authorization (SMPA) Request Forms to Texas Medicaid & Healthcare Partnership (TMHP) with required clinical documentation (congenital athymia confirmed by flow cytometry [D821], SCID ruled out, anti-HLA antibody testing results, prescriber attestation for CMV/renal impairment assessment); (3) Train clinical staff on eligibility criteria (patient age ≤18 years, lifetime procedure limit); (4) Update encounter forms to capture required clinical data before claim submission; (5) Ensure providers understand post-implantation monitoring requirements (GVHD, autoimmune/lymphoproliferative disorders, renal impairment, infectious disease). Contact TMHP Contact Center at 800-925-9126 for questions. For MCO members, verify specific MCO prior authorization procedures as they may differ from traditional Medicaid. Claims submitted without prior authorization will be denied.