MedicaidPrior AuthMedium impact
Prior Authorization Criteria for Pivekimab Sunirine-pvzy (Decnupaz) Effective November 1, 2026
Texas Medicaid·TX · Oncology, Hematology·Prior Authorization
Effective date
Nov 1, 2026
We identified it
Sep 30, 2026
Summary
Effective November 1, 2026, Texas Medicaid (TMHP) now requires prior authorization for pivekimab sunirine-pvzy (Decnupaz), a CD-123 directed antibody used to treat blastic plasmacytoid dendritic cell neoplasm (BPDCN). Prior authorization requests must be submitted on the Special Medical Prior Authorization (SMPA) Request Form and must meet specific clinical criteria including age 18+, confirmed BPDCN diagnosis, CD-123 positive disease, baseline hepatic function testing, and provider attestation of VOD monitoring.
Action Required
By November 1, 2026: Billing team and providers must implement prior authorization process for pivekimab sunirine-pvzy (Decnupaz) procedure code C9313 for all Texas Medicaid (TMHP) patients. (1) Update billing system to flag C9313 claims for TMHP members as requiring prior authorization. (2) Create workflow to route all C9313 requests through SMPA Form submission process before treatment initiation. (3) Train providers and clinical staff on initial authorization criteria: patient age 18+, BPDCN diagnosis (C8640, excluding APL), CD-123 positive disease, baseline AST/ALT/bilirubin testing, and provider attestation of VOD monitoring commitment. (4) For renewal/continuation, ensure documentation of prior treatment with tagraxofusp-erzs (Elzonris) or pivekimab sunirine-pvzy without adverse reactions and evidence of positive clinical response (disease stabilization). (5) Establish process to contact TMHP Contact Center (800-925-9126) with questions. Claims submitted without prior authorization will be denied. Note: Contact patient's specific MCO for MCO-specific prior authorization procedures as they may differ from TMHP fee-for-service requirements.