Start free

PolicyChanges tracks payer policy changes for medical practices and tells you what to do before they take effect.

Create a free accountPolicy Monitoring is free. No card required.
← Back to list
HumanaMedicaid · Prior Auth · Medicaid · KY · Oncology, Hematology, PediatricsHigh impact

Kymriah™ (tisagenlecleucel) (Revised)

Act
by Aug 26, 2026
Effective date
Aug 26, 2026
Identified
Aug 26, 2026

Summary

Humana Kentucky Medicaid has revised its Kymriah (tisagenlecleucel) prior authorization policy effective August 26, 2026. The policy maintains three distinct approval pathways for large B-cell lymphoma (DLBCL and follicular lymphoma) in adults ≥18 years, and B-cell precursor acute lymphoblastic leukemia (ALL) in patients up to 25 years. All approvals require prior authorization, are limited to one lifetime dose, and require lymphodepleting chemotherapy unless contraindicated. Key exclusions include prior gene therapy, prior anti-CD19/anti-CD3 therapies, active hepatitis B/C, HIV/AIDS, and (for lymphoma cases) prior allogeneic transplant or CNS lymphoma.

Get alerts when payers change rules like this one

We check Humana and other payers every day and email you when a change matches your specialty and state.

Get Humana alertsPolicy Monitoring is free. No card required.

What to do

by Aug 26, 2026 · 8 steps
01Billing team must implement prior authorization requirement for Kymriah (J7174) for all Kentucky Medicaid claims.
02Update billing system to flag all J7174 claims requiring prior auth before submission.
03Modify claim submission workflow to route J7174 requests to Corporate Transplant Department (1-866-421-5663, fax 502-508-9300, email transplant@humana.com) for approval before dispensing.
04Train billing staff to verify member eligibility against all seven criteria for applicable diagnosis (DLBCL/follicular lymphoma or ALL) and ALL six exclusion criteria before submitting requests.
05Ensure prior auth requests include: diagnosis confirmation, documentation of prior systemic therapy lines (2+ required), evidence of relapsed/refractory disease, CD19 expression results (for ALL), age verification, and lymphodepleting chemotherapy regimen details.
06Document that maximum one dose per lifetime applies and alert providers/patients of this limitation.
07Flag claims for members with prior gene therapy, prior anti-CD19/anti-CD3 therapy, hepatitis B (HBsAg-positive), hepatitis C, HIV/AIDS, or (for lymphoma) prior allogeneic transplant or CNS lymphoma for denial.
08Set initial and renewal approval duration to 60 days in system.
If missed: Failure to obtain prior authorization will result in claim denials.

Codes mentioned

J7174

Original notice

Kymriah™ (tisagenlecleucel) (Revised)
mcp.humana.com · Always check the source before changing claims.
View original ↗

Related changes

See all Humana changes →
IVIG (immune globulin) (Revised)HighEffective Jan 1, 2026 · MedicaidPreferred Adalimumab Products (Revised)HighEffective Jan 1, 2026 · Medicare AdvantageEpoetin Alfa (Epogen, Procrit, Retacrit) (Revised)HighEffective Jan 1, 2025 · MedicaidFactor VIII Replacement Products (Hemophilia A) (Revised)MediumEffective Dec 17, 2025 · MedicaidBrowse every Humana change in the policy list

Related policy hubs

Humana policiesKY policy changesOncologyHematologyPediatricsCode J7174

Summaries are AI-assisted. Always confirm against the original payer notice.

What is PolicyChanges

One workspace for payer rules, prior auth, coding and compliance

Medical practices use PolicyChanges to catch payer changes before they cause denials. Every change is summarized in plain English, with the codes involved, the date it takes effect and what to do.

Policy MonitoringPayer policy, prior auth and coding changes, filtered to your saved searchesOIG ScreeningStaff and vendors screened every month against OIG LEIE, SAM.gov and state Medicaid listsPrior Auth LookupKnow if a service needs prior authorization before you schedule itCredentialing TrackerLicenses, CAQH, Medicare revalidation and payer enrollments, with reminders before anything lapsesCompliance CenterKeep your HIPAA program documented and ready to show
Start freePolicy Monitoring is free. No card required.
Get alerts for changes like thisPolicy Monitoring is free. No card required.Create a free account