Prior Authorization for Lymphir

Date: April 6, 2026

Attention: Providers

Effective date for benefit: April 1, 2026
Effective date for Prior Authorization: May 1, 2026

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that Texas Health and Human Services Commission (HHSC) will add Lymphir (procedure code J9161) as a Medicaid and CHIP benefit beginning April 1, 2026, and requires prior authorization for those programs effective May 1, 2026.

Lymphir (denileukin diftitox-cxdl) is an IL-2 receptor-directed cytotoxin indicated for the treatment of adult patients with relapsed or refractory Stage I-III cutaneous T-cell lymphoma (CTCL) after at least one prior systemic therapy.

• Prior authorization is required for Lymphir (denileukin diftitox-cxdl).
• The initial prior authorization request for Lymphir (denileukin diftitox-cxdl) may be approved for 12 months for patients who meet the following requirements:

1. Patient is 18 years or older.
2. Patient has a confirmed diagnosis of cutaneous T-cell lymphoma (CTCL).
   1. Patient’s lymphoma is categorized as Stage I to III

   2. Patient’s CTCL is relapsed or refractory after at least one prior systemic treatment.

      Table A: Diagnosis code for CTCL (Mycosis Fungoides or Sézary Syndrome)

      C84.00	C84.01	C84.02	C84.03	C84.04	C84.05
      C84.06	C84.07	C84.08	C84.09	C84.10	C84.11
      C84.12	C84.13	C84.14	C84.15	C84.16	C84.17
      C84.18	C84.19	C84.A0	C84.A1	C84.A2	C84.A3
      C84.A4	C84.A5	C84.A6	C84.A7	C84.A8	C84.A9
      C84.AA

3. The patient’s serum albumin level must be greater than 3 g/dL prior to treatment cycle.

4. The prescriber attests to counseling female patients of childbearing age regarding the use of an effective method of contraception during treatment with Lymphir (denileukin diftitox-cxdl), as there may be a potential risk to the fetus.

   Monitoring parameters:

5. Monitor for signs and symptoms of Capillary Leak Syndrome (e.g., low blood pressure, severe swelling)
6. Monitor patient’s liver enzymes and bilirubin at baseline and during treatment as hepatotoxicity may occur.
7. Monitor patient’s renal function prior to starting each treatment. If serum albumin is less than 3 g/dL, delay administration of LYMPHIR until serum albumin is greater than or equal to 3 g/dL.
8. Monitor and evaluate for any visual impairment throughout treatment.
   - For renewal or continuation of denileukin diftitox-cxdl (Lymphir) therapy the client must meet the following requirements:
   • Client met initial requirements for prior authorization and is currently treated with denileukin diftitox-cxdl with the absence of severe adverse reactions or unacceptable toxicity (e.g., visual impairment, infusion related reactions, or hepatotoxicity).
   • Client demonstrates partial/complete response to treatment or stabilization of disease, as shown by a decrease in spread or size of the tumor.

Next step for providers: Providers should share this communication with their staff.

If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org. 

For access to all provider alerts www.texaschildrenshealthplan.org/provideralerts.