By Counterforce Health Team in Kymriah (tisagenlecleucel) —

How to Get Kymriah (tisagenlecleucel) Covered by Blue Cross Blue Shield in Virginia: Decision Tree, Appeals, and Next Steps

Answer Box: Getting Kymriah Coverage in Virginia

Kymriah (tisagenlecleucel) requires prior authorization from all Blue Cross Blue Shield plans in Virginia as of July 2024. Your fastest path to approval: (1) Confirm treatment at a BCBS-certified CAR-T center, (2) Have your oncologist submit comprehensive clinical documentation through Anthem's Availity portal showing medical necessity, and (3) Include proof of CD19-positive disease and failed prior therapies. If denied, Virginia offers expedited external review through the State Corporation Commission within 72 hours for urgent cancer cases. Start today: Call your BCBS member services to confirm your specific PA requirements and locate certified treatment centers.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Your Action Plan
  4. If "Possibly Eligible": Tests and Timeline
  5. If "Not Yet": Alternatives and Exceptions
  6. If Denied: Virginia Appeal Path
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. Clinician Corner: Medical Necessity Documentation
  10. Costs and Patient Support Programs
  11. FAQ: Virginia-Specific Questions

How to Use This Decision Tree

This guide helps you navigate Kymriah coverage with Blue Cross Blue Shield in Virginia systematically. Start with the eligibility triage below to determine your likely approval path, then follow the corresponding action steps.

Kymriah is an FDA-approved CAR-T therapy for specific blood cancers, with a list price around $373,000-$475,000 depending on indication. All BCBS plans in Virginia—including Anthem Blue Cross Blue Shield and CareFirst—require prior authorization and treatment at certified centers.

Note: This process typically takes 2-4 weeks from submission to decision, so start early if your treatment is scheduled.

Eligibility Triage: Do You Qualify?

Answer these questions to determine your approval likelihood:

Diagnosis Requirements ✓

  • B-cell precursor ALL (age ≤25): Relapsed/refractory after standard therapy
  • DLBCL (adults): Relapsed/refractory after 2+ lines of systemic therapy
  • Primary mediastinal B-cell lymphoma (adults): Relapsed/refractory after 2+ lines
  • Follicular lymphoma (adults): Relapsed/refractory after 2+ lines

Clinical Criteria ✓

  • CD19-positive disease confirmed by pathology
  • ECOG performance status 0-2 (or Karnofsky ≥60%)
  • Adequate organ function for CAR-T therapy
  • No active CNS disease (unless specifically indicated)

Treatment Center ✓

  • Scheduled at a BCBS-certified Blue Distinction Center for Cellular Immunotherapy
  • FACT-accredited facility for immune effector cell therapy
  • In-network with your specific BCBS plan

Your Result:

  • All boxes checked = "Likely Eligible" → Proceed to Section 3
  • Missing 1-2 items = "Possibly Eligible" → See Section 4
  • Missing 3+ items = "Not Yet" → Review Section 5

If "Likely Eligible": Your Action Plan

Step 1: Confirm Your Treatment Center

Contact your BCBS plan to verify your chosen facility is certified for CAR-T therapy. In Virginia, major certified centers typically include:

  • University of Virginia Medical Center (Charlottesville)
  • VCU Health/Massey Cancer Center (Richmond)
  • Inova Schar Cancer Institute (Northern Virginia)
Tip: Ask for the current list—certifications change regularly.

Step 2: Gather Required Documentation

Your oncologist needs these items for the PA submission:

  • Complete medical history and physical exam
  • Pathology report confirming CD19+ disease
  • Documentation of prior therapy failures/intolerance
  • Current imaging and lab results
  • ECOG performance status assessment
  • Treatment plan including conditioning regimen

Step 3: Submit Prior Authorization

For Anthem BCBS Virginia: Submit through Availity Essentials portal with all clinical documentation.

Timeline: Standard PA decisions within 14 days; expedited reviews within 72 hours for urgent cases.

Step 4: Track Your Submission

  • Save your PA confirmation number
  • Follow up if no response within the stated timeframe
  • Be prepared to provide additional clinical information if requested

If "Possibly Eligible": Tests and Timeline

Missing diagnostic confirmation? Request these tests from your oncologist:

  • Flow cytometry or immunohistochemistry for CD19 expression
  • Bone marrow biopsy (if not recent)
  • Updated imaging (PET/CT within 30 days)

Performance status concerns? Document current functional status and any improvements with supportive care.

Center not certified? Ask your oncologist about transfer options to a BCBS-approved facility, or request a network exception if medically necessary.

Re-application timeline: Once missing elements are addressed, allow 2-3 weeks for PA processing.

If "Not Yet": Alternatives and Exceptions

Alternative CAR-T Options

If Kymriah isn't immediately appropriate, discuss these FDA-approved alternatives:

  • Yescarta (axicabtagene ciloleucel) - for DLBCL, PMBCL, FL
  • Breyanzi (lisocabtagene maraleucel) - for DLBCL, PMBCL, FL
  • Tecartus (brexucabtagene autoleucel) - for MCL, ALL

Exception Request Strategy

For off-label or compassionate use cases:

  1. Document why standard therapies have failed
  2. Cite peer-reviewed literature supporting Kymriah use
  3. Include oncologist's detailed medical necessity letter
  4. Reference NCCN guidelines where applicable

If Denied: Virginia Appeal Path

Level 1: Internal Appeal (First-Line Defense)

Timeline: File within 180 days of denial notice Process: Submit appeal form with:

  • Original denial letter
  • Additional clinical documentation
  • Point-by-point rebuttal of denial reasons
  • Updated medical necessity letter

Success rate: 70-78% overturn rate for well-documented specialty drug appeals

Level 2: Peer-to-Peer Review

Request a clinical discussion between your oncologist and BCBS medical director. This often resolves complex cases before formal external review.

Level 3: Virginia External Review

When to use: After internal appeals are exhausted or for urgent cases Timeline: File within 120 days of final denial Forms: Virginia External Review Request Form (Form 216-A) Submit to:

  • Fax: (804) 371-9944
  • Mail: State Corporation Commission, Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218

Expedited review: Available for urgent cancer cases—decision within 72 hours

Virginia Advantage: The state allows expedited external review for cancer treatment denials without exhausting all internal appeals first.

Coverage Requirements at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all BCBS plans Anthem PA Requirements
Treatment Center BCBS-certified Blue Distinction Center Contact member services
Diagnosis FDA-approved indications only FDA Kymriah Label
CD19 Status Must be positive by pathology Medical records
Prior Therapy 2+ failed lines (varies by indication) Treatment history
Appeal Deadline 180 days (internal), 120 days (external) Virginia SCC

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Experimental/Investigational" Cite FDA approval date, include label excerpt, reference NCCN guidelines
"Not medically necessary" Document failed prior therapies, include oncologist rationale, cite survival data
"Non-certified facility" Transfer to approved center or request network exception
"Missing CD19 confirmation" Submit pathology report with immunohistochemistry results
"Inadequate prior therapy" Document specific agents tried, dates, and reasons for discontinuation

Clinician Corner: Medical Necessity Documentation

Essential Elements for PA Submission:

  1. Patient demographics and diagnosis (include ICD-10 codes)
  2. Disease characteristics: CD19 status, staging, molecular markers
  3. Treatment history: Specific regimens, dates, response, toxicities
  4. Current status: Performance status, organ function, imaging results
  5. Rationale: Why Kymriah is appropriate now, expected benefits
  6. Treatment plan: Conditioning regimen, monitoring, supportive care

Key Citations to Include:

From our advocates: "We've seen the strongest approvals when oncologists include specific details about why other CAR-T options aren't suitable—whether due to manufacturing timelines, patient factors, or institutional experience. BCBS medical directors appreciate this level of clinical reasoning."

Costs and Patient Support Programs

Manufacturer Support

Novartis Oncology Patient Assistance:

  • Copay assistance for eligible patients
  • Free drug program for uninsured/underinsured
  • Contact: 1-800-282-7630

Foundation Resources

  • Leukemia & Lymphoma Society: Financial assistance, copay support
  • CancerCare: Treatment-related financial assistance
  • Patient Access Network Foundation: CAR-T specific grants

Virginia-Specific Resources

  • Virginia Cancer Institute: Patient navigation services
  • Virginia Medicaid: Expanded coverage since 2019 may help with eligibility

FAQ: Virginia-Specific Questions

Q: How long does BCBS prior authorization take in Virginia? A: Standard PA reviews take up to 14 days. Expedited reviews (for urgent cases) are completed within 72 hours.

Q: What if my oncologist isn't at a certified center? A: You'll need to transfer care to a BCBS-approved facility or request a network exception. Your oncologist can help coordinate the transfer.

Q: Can I appeal if I'm denied for being "too sick" for CAR-T? A: Yes. Request peer-to-peer review to discuss your specific clinical situation. Sometimes additional supportive care can improve candidacy.

Q: Does step therapy apply to CAR-T therapies? A: BCBS typically requires documentation of failed conventional therapies, but formal step therapy protocols vary by plan. Check your specific policy.

Q: What's the success rate for external review in Virginia? A: Virginia doesn't publish specific CAR-T overturn rates, but external reviews generally favor patients when clinical evidence supports medical necessity.

Q: Can I get expedited review for Kymriah in Virginia? A: Yes, if your oncologist certifies that delay would seriously jeopardize your health. Virginia allows expedited external review for cancer treatment denials.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Our platform helps patients and clinicians navigate complex prior authorization requirements for specialty therapies like CAR-T, dramatically improving approval rates through systematic documentation and appeal strategies.

For additional support with your Kymriah appeal or prior authorization, Counterforce Health provides tools and expertise to help you build the strongest possible case for coverage.

Sources & Further Reading

Disclaimer: This guide is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For official appeals assistance in Virginia, contact the State Corporation Commission Bureau of Insurance at 1-800-552-7945.

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