Tisagenlecleucel (Kymriah) (CPB 0920, reviewed 2026-09-11)

IMMEDIATE: Billing team must implement mandatory precertification workflow for all Tisagenlecleucel (Kymriah) claims. REQUIREMENTS: (1) Before ANY service is rendered, contact National Medical Excellence (NME) at 1-877-212-8811 to obtain precertification for all applicable plan designs. (2) Verify patient meets ALL coverage criteria including: pediatric/young adult age limits (under 26 for ALL), CD19 tumor expression, adequate performance status (Karnofsky ≥50% or Lansky ≥50%), prior treatment history, and absence of exclusionary conditions (previous CAR-T therapy, active infections, graft-versus-host disease, hepatitis B/C, inadequate organ function). (3) Update billing system to flag CPT codes 38225-38228 and HCPCS Q2042 for mandatory prior authorization requirement before claim submission. (4) Ensure providers document CD19 expression status, lymphoblast percentage, prior TKI treatment history (for Philadelphia chromosome-positive disease), and performance status in medical record. (5) Do NOT submit claims without precertification approval or they will be denied. (6) Front desk/scheduling staff must screen patients during registration to identify Kymriah candidates and initiate precertification process prior to leukapheresis appointment. Failure to obtain precertification will result in claim denials and patient financial liability.