Pralatrexate — CPB 0740 | AETNA Coverage Update

Aetna modified CPB 0740 for pralatrexate (Folotyn), effective September 26, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its pralatrexate coverage policy under CPB 0740 on September 26, 2025. This change defines medical necessity criteria across eight T-cell malignancy indications. The primary billing code affected is HCPCS J9307 (injection, pralatrexate, 1 mg), along with administration codes CPT 96374 and 96375. If your oncology or hematology practice bills Aetna for pralatrexate, audit your prior authorization workflows and ICD-10 coding before claims go out.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Pralatrexate (Folotyn) — CPB 0740
Policy Code	CPB 0740
Change Type	Modified
Effective Date	September 26, 2025
Impact Level	High
Specialties Affected	Oncology, Hematology, Infusion Therapy
Key Action	Confirm each claim maps to a covered indication with the correct single-agent or line-of-therapy criteria before billing J9307

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Aetna Pralatrexate Coverage Criteria and Medical Necessity Requirements 2025

The Aetna pralatrexate coverage policy under CPB 0740 Aetna system covers eight distinct T-cell malignancy indications. Each one carries its own set of conditions. Getting even one criterion wrong on a prior authorization request or a claim will get you a denial.

Here's the short version: pralatrexate must almost always be used as a single agent. Combination use is only permitted in one indication — subcutaneous panniculitis-like T-cell lymphoma, where Aetna allows pralatrexate combined with prednisone. Every other indication requires single-agent use as a hard condition for medical necessity.

Adult T-Cell Leukemia/Lymphoma (ATLL)

Aetna covers pralatrexate for ATLL when used as a single agent and as subsequent (not first-line) therapy.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (ALCL)

Coverage requires single-agent use and subsequent therapy. First-line use is not covered under this indication.

Cutaneous Anaplastic Large Cell Lymphoma

This is one of the simpler criteria. Single-agent use is the only requirement. Line of therapy is not specified.

Extranodal NK/T-Cell Lymphoma

This indication has the most restrictive criteria. All three of the following must be met:

#	Covered Indication Copy
1	Single-agent use
2	Relapsed or refractory disease
3	Inadequate response to — or contraindication to — asparaginase-based therapy (e.g., pegaspargase)

If the member hasn't failed asparaginase-based therapy and doesn't have a documented contraindication, expect a claim denial.

Hepatosplenic T-Cell Lymphoma

Coverage requires single-agent use and at least two prior lines of chemotherapy. Document those prior lines in the record before submitting prior authorization.

Mycosis Fungoides or Sézary Syndrome (MF/SS)

No additional criteria beyond the diagnosis. Single-agent use is not explicitly required here — this is one of the few indications where the policy is less restrictive on use conditions.

Peripheral T-Cell Lymphoma (PTCL)

Aetna covers pralatrexate for PTCL including these subtypes: anaplastic large cell lymphoma, PTCL not otherwise specified (NOS), angioimmunoblastic T-cell lymphoma, enteropathy-associated T-cell lymphoma, monomorphic epitheliotropic intestinal T-cell lymphoma, nodal peripheral T-cell lymphoma with TFH phenotype, and follicular T-cell lymphoma.

Two conditions apply: single-agent use, and either relapsed/refractory disease or initial palliative therapy.

Subcutaneous Panniculitis-Like T-Cell Lymphoma

The only indication where combination therapy is allowed. Pralatrexate may be used as a single agent or combined with prednisone.

Continuation of Therapy

Aetna considers continuation medically necessary when there's no evidence of unacceptable toxicity or disease progression. Document response to treatment at each assessment. Continued therapy reimbursement depends on that documentation being in the record.

Vitamin B-12 supplementation is medically necessary for all members taking pralatrexate. Bill it separately under CPB 0536. Don't skip this — it's not optional under Aetna's policy.

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Aetna Pralatrexate Exclusions and Non-Covered Indications

Aetna's position is explicit: all other indications not listed in Section I are considered experimental, investigational, or unproven. There's no gray area here.

If a physician requests pralatrexate for a solid tumor or a non-T-cell lymphoma — even one with emerging literature — Aetna will deny it under this coverage policy. The ICD-10 code list in CPB 0740 includes codes for nasopharyngeal cancers, esophageal cancers, gastric cancers, lung cancers, breast cancers, ovarian cancers, and melanoma, among others. Those codes appear in the policy as "other CPT codes related to the CPB," not as covered indications.

The real issue here: a claim submitted with a solid tumor diagnosis and J9307 will almost certainly be denied. Make sure your oncology coding team knows which diagnoses Aetna covers before billing pralatrexate.

If you're treating a patient with an off-label indication and believe pralatrexate is medically necessary, talk to your compliance officer and billing consultant before submitting. The gap between "clinically indicated" and "Aetna-covered" is wide on this drug.

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Coverage Indications at a Glance

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Aetna Pralatrexate Billing Guidelines and Action Items 2025

Here's what your billing team needs to do before submitting any pralatrexate claim under the updated CPB 0740 policy.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Pralatrexate Under CPB 0740

Covered HCPCS Code (When Selection Criteria Are Met)

Code	Type	Description Copy
J9307	HCPCS	Injection, pralatrexate, 1 mg

Key ICD-10-CM Diagnosis Codes

The policy lists 148 ICD-10-CM codes. The T-cell malignancy codes that align directly with the eight covered indications are the ones your billing team needs to verify. The broader code set in the policy includes solid tumor diagnoses that are not covered indications — those codes appear in the policy for reference, not for coverage.

The full ICD-10-CM code list in CPB 0740 contains 148 codes. Review the complete list at the Aetna CPB 0740 source document to verify all applicable diagnosis codes before billing.

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