MedicaidPrior AuthMedium impact
BT202135: IHCP clarifies PA criteria for HCPCS code J0791
Indiana Medicaid (IHCP)·IN · Hematology, Oncology·Claims & Billing
Effective date
May 4, 2021
We identified it
Jun 19, 2026
Summary
IHCP (Indiana Medicaid) has clarified prior authorization criteria for HCPCS code J0791 (crizanlizumab-tmca injection) for sickle cell disease treatment. Specific medical necessity criteria now include age requirements, diagnosis confirmation, hydroxyurea therapy status, and recent vaso-occlusive crisis history.
Action Required
Immediately: Billing team must update prior authorization protocols for HCPCS J0791 to include new medical necessity criteria: patient 16+ years old, sickle cell disease diagnosis, hydroxyurea therapy status, vaso-occlusive crisis within 12 months, and proper dosing (5 mg/kg IV). Update encounter forms and provider checklists. For managed care patients, contact specific MCE for approval requirements.