Enzyme Replacement Therapy Prior Authorization Update

Date: February 26, 2024

Attention: All Providers

Effective date: February 1, 2024

Call to action: Texas Children’s Health Plan would like to make providers aware of prior authorization updates for certain enzyme replacement therapies. In alignment with Texas Medicaid Provider Procedure Manual (TMPPM) requirements, effective for dates of service on or after February 1, 2024, prior authorization will be required for enzyme replacement therapy velmanse alfa-tycv (Lamzede), procedure code J0217, and pegunigalsidase alfa-iwxj (Elfabrio), procedure code J2508.

Prior Authorization Requirements include the following:

• Velmanse alfa-tycv (Lamzede)
  • Prior authorization is required for procedure code J0217
  • Procedure code J0217 (Lamzede) is indicated to treat non-central nervous system manifestation of alpha-mannosidosis in adult and pediatric clients and may be reimbursed with diagnosis code E771. The pregnancy status of female clients of reproductive potential must be verified prior to the start of treatment. 

• Pegunigalsidase alfa-iwxj (Elfabrio)
  • Prior authorization is required for procedure code J2508
  • Procedure code J2508 (Elfabrio) is indicated for the treatment of adult clients with confirmed Fabry disease and may be reimbursed with diagnosis code E7521.  (FDA approved 18 and older) 

Next step for Providers: Providers should follow the prior authorization guidelines as stated above and 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,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.