Plerixafor — CPB 0779 | AETNA Coverage Update

Aetna modified CPB 0779 covering plerixafor (Mozobil) stem cell mobilization, effective February 14, 2026. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its coverage policy for plerixafor injection (HCPCS J2562) under CPB 0779 Aetna's hematopoietic stem cell mobilization policy. The revision clarifies the medical necessity criteria for initial approval and continuation of therapy, including a new explicit pathway for gene therapy protocols. If your team bills J2562 alongside G-CSF codes like J1442 or J2505, this update affects how you document and submit those claims.

Quick-Reference Table

Aetna Plerixafor Coverage Criteria and Medical Necessity Requirements 2026

The Aetna plerixafor coverage policy under CPB 0779 is more structured than it looks. Two criteria must both be met — not just one. Miss either one and you're looking at a claim denial.

Criterion one: qualifying administration scenario. Plerixafor (billed as J2562) must be administered in at least one of these three contexts:

The gene therapy pathway is the notable addition here. This brings plerixafor billing squarely into the gene therapy space, which is seeing rapid growth. If your center is running gene therapy protocols that require stem cell mobilization, this opens a clear medical necessity path — but only if your documentation names the protocol explicitly.

Criterion two: duration limit. Plerixafor use cannot exceed four consecutive days or extend beyond completion of stem cell harvest/apheresis. That's a hard stop. If your billing team is seeing claims that run longer, flag them for review before they go out. The effective date of February 14, 2026, means this applies to claims processed on or after that date.

Prior authorization requirements are not explicitly detailed in this policy update, but plerixafor is a specialty injectable — assume prior auth is required for most Aetna commercial plans. Verify prior authorization status before administering, especially for gene therapy cases, where the clinical documentation requirements will be more complex.

Reimbursement for J2562 flows through the standard specialty drug administration channel. Bill CPT 96372 for the subcutaneous or intramuscular injection when administered in an outpatient setting. Pair it with the appropriate G-CSF HCPCS code to support the qualifying scenario documentation.

Aetna Plerixafor Exclusions and Non-Covered Indications

Aetna's position here is unambiguous: any use of plerixafor outside the three qualifying scenarios is considered experimental, investigational, or unproven. There's no gray area in the policy language.

That means off-label use — outside of post-G-CSF mobilization, post-chemo-mobilization, or a gene therapy protocol — won't get paid. Don't submit J2562 claims for investigational protocols not covered by these three pathways expecting coverage. You'll get denied, and an appeal won't change the underlying policy.

The real issue here is documentation. The three qualifying scenarios are clinically specific. If a claim comes in without documentation tying the plerixafor administration to one of those three contexts, Aetna will treat it as unproven use. Your clinical team needs to know this — the billing team can't build that case after the fact.

Coverage Indications at a Glance

Aetna Plerixafor Billing Guidelines and Action Items 2026

The plerixafor billing guidelines under CPB 0779 require a few concrete changes to how your team documents and submits these claims. Here's what to do before February 14, 2026 and on an ongoing basis.

If you're managing a high volume of stem cell transplant or gene therapy cases, talk to your compliance officer before the February 14, 2026 effective date. The gene therapy pathway in particular is new enough that your team's documentation standards may need updating.

CPT, HCPCS, and ICD-10 Codes for Plerixafor Stem Cell Mobilization Under CPB 0779

Covered HCPCS Code (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes

The policy lists 184 ICD-10-CM codes. Below is the full set from the policy data. These represent the covered diagnosis universe for CPB 0779.

The full 184-code ICD-10-CM list is available in the complete CPB 0779 policy document. The policy covers a broad range of hematologic malignancies, leukemias, lymphomas, and other conditions requiring stem cell mobilization.