Etuvetidigene Autotemcel (Waskyra) (CPB 1097)

IMMEDIATELY: (1) Billing team must establish precertification requirement for all Waskyra administrations by contacting National Medical Excellence (NME) at 877-212-8811 before patient treatment. Update billing system to flag CPT codes 38225-38228, 38206-38207, 36511, and 88184-88187 with mandatory precertification requirement. (2) Providers must verify patient eligibility against all criteria in CPB 1097 before scheduling: patient age ≥6 months, confirmed WAS gene mutation with abnormal WASP expression or severe clinical phenotype (Zhu score ≥3), no HLA-identical sibling donor available, negative HIV/Hepatitis C status, and no contraindicated conditions (active TB, malignancy, end-organ dysfunction, etc.). (3) Verify treatment will occur at Aetna Institutes GCIT Designated Network facility; non-network administration may result in claim denial. (4) Update encounter documentation templates to require provider confirmation of all 13 eligibility criteria and treatment plan sign-off by immunologist, hematologist, or WAS specialist. (5) Create internal checklist for billing staff to verify: precertification approval obtained, provider specialty documented, network facility confirmed, and ICD-10 code D82.0 correctly linked before claim submission. Failure to obtain precertification will result in claim denials. Claims submitted for ineligible patients or non-network facilities will be denied.