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Medical Policy Update: Tisagenlecleucel (Kymriah)

Effective October 8, 2019, Horizon BCBSNJ will change the way we consider certain professional claims for services provided to Horizon BCBSNJ Medicare Advantage (MA) members based on an update to our medical policy, Tisagenlecleucel (Kymriah).

Access our Medical Policy Manual to review this medical policy content.¹

Regardless of the submitted diagnosis code(s), claims submitted for services provided on and after October 8, 2019 to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans will be processed as follows.

  • The services represented by CPT® codes 0537T, 0538T or 0539T will be denied as not eligible for separate reimbursement.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after October 8, 2019.

¹ The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

Kymriah® is a registered trademark of Novartis Pharmaceuticals Corporation. This document contains references to brand name prescription medicines that are trademarks or registered marks of pharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association

Published on: September 6, 2019, 02:46 a.m. ET
Last updated on: June 23, 2021, 09:28 a.m. ET