Prior Authorization Criteria for Decnupaz

Date: October 8, 2026

Attention: All Providers

Effective date: November 1, 2026

Call to action: Texas Children's Health Plan (TCHP) would like to inform providers that effective for dates of service on or after November 1, 2026, prior authorization will be required for pivekimab sunirine-pvzy (Decnupaz) (procedure code C9313).

Pivekimab sunirine-pvzy (Decnupaz) is a CD 123-directed antibody and alkylating agent conjugate indicated to treat blastic plasmacytoid dendritic cell neoplasm (BPDCN).

Prior Authorization Criteria

Prior authorization requests for pivekimab sunirine-pvzy (Decnupaz) must be submitted on the Special Medical Prior Authorization (SMPA) Request Form.

Prior Authorization Requests for Initial Therapy

The Texas Medicaid & Healthcare Partnership (TMHP) may approve initial therapy for pivekimab sunirine-pvzy (Decnupaz) (procedure code C9313) annually for a duration of 12 months if the patient meets all the following criteria:

• The patient is 18 years of age or older.
• The patient has a diagnosis of blastic plasmacytoid dendritic cell neoplasm excluding acute promyelocytic leukemia (APL, FAB, M3) (diagnosis code C8640).
• The patient has a CD-123 positive/expressing disease.
• The patient does not have moderate-to-severe hepatic impairment. Baseline aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin must be obtained and reviewed prior to treatment with pivekimab sunirine-pvzy (Decnupaz).
• Pivekimab sunirine-pvzy (Decnupaz) may cause hepatotoxicity, including veno-occlusive disease (VOD), a severe form of hepatotoxicity.
  • The patient’s hepatic function must be monitored before the start of each course of therapy to mitigate the risk of severe or fatal VOD.
  • Treatment with pivekimab sunirine-pvzy (Decnupaz) should be delayed with liver test elevations and permanently discontinued in patients who experience VOD.
• The prescribing provider attests that they will closely monitor for signs and symptoms of VOD including elevations in liver tests, hepatomegaly, rapid weight gain, and ascites.

Prior Authorization Requests for Renewal or Continuation of Therapy

For renewal or continuation of therapy of pivekimab sunirine-pvzy (Decnupaz), the patient must meet the following requirements:

• The patient continues to meet initial prior authorization approval criteria.
• The patient has previously received treatment with tagraxofusp-erzs (Elzonris) or pivekimab sunirine-pvzy (Decnupaz) without adverse drug reactions or drug toxicity.
• The patient has a positive clinical response demonstrated by disease stabilization.

Next step for providers: Providers should share this information 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.