08.02.23, Tislelizumab-jsgr (Tevimbra®)

By August 25, 2025: Billing and clinical teams must implement the following: (1) Update billing system logic to enforce medical necessity criteria for HCPCS code J9329 (tislelizumab-jsgr injection) across all covered cancer indications listed in policy 08.02.23b; (2) Configure automated edits to flag claims missing required documentation (e.g., mutation status, TMB >50 mut/Mb for appendiceal cancer, prior immunotherapy history, performance status); (3) Establish prior authorization workflow requiring providers to submit documentation of applicable medical necessity criteria before dispensing; (4) Train billing and clinical staff on the 11 covered cancer indications and their specific criteria (e.g., second-line vs. first-line use, combination therapy requirements, mutation requirements); (5) Update encounter forms and EMR templates to prompt providers to document applicable criteria; (6) Audit all pending and recently submitted J9329 claims against new criteria and resubmit or deny accordingly. Note: Policy 08.02.23 is superseded and should be removed from active use. Failure to implement will result in claim denials for non-compliant submissions.