MedicaidPrior AuthMedium impact
Benefit and Prior Authorization Criteria for Eladocagene Exuparvovec-tneq (Kebilidi)
Texas Medicaid·TX · Neurology, Pediatrics, Genetics·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jul 30, 2026
Summary
Texas Medicaid is adding eladocagene exuparvovec-tneq (Kebilidi), a gene therapy for AADC deficiency, as a covered benefit effective July 1, 2026. Prior authorization will be required beginning September 1, 2026, and providers must submit requests using the Special Medical Prior Authorization (SMPA) form. This therapy is limited to one lifetime infusion per patient and requires strict clinical criteria including age 16 months or older, confirmed AADC diagnosis, biallelic DDC gene mutations, and skull maturity documentation.
Action Required
By September 1, 2026: Billing team must implement prior authorization workflow for procedure code J3590 (eladocagene exuparvovec-tneq). Update billing system to flag all J3590 claims requiring Special Medical Prior Authorization (SMPA) submission before claims are processed. Verify patient meets all clinical criteria before submitting (age ≥16 months, ICD-10 diagnosis E7081, documented biallelic DDC mutations, skull maturity confirmation via neuroimaging). Ensure one-infusion-per-lifetime limit is tracked in patient records to prevent duplicate authorizations. Train providers and clinical staff on prior authorization requirements and monitoring parameters post-infusion (respiratory/cardiac complications, cerebrospinal fluid leak, intracranial bleeding, neuroinflammation, dyskinesia). Contact TMHP at 800-925-9126 for clarification and note that MCO procedures may differ from fee-for-service Medicaid. Claims submitted without prior authorization will be denied.