Aetna Modified CPB 0823 for Brentuximab Vedotin (Adcetris), Effective February 25, 2026 — Here's What Billing Teams Need to Do
Aetna, a CVS Health company, modified CPB 0823, its clinical policy bulletin covering brentuximab vedotin (Adcetris), with an effective date of February 25, 2026. This Aetna brentuximab vedotin coverage policy governs medical necessity criteria across a wide range of hematologic and cutaneous malignancies — including classic Hodgkin lymphoma, several B-cell non-Hodgkin lymphoma subtypes, and CD30+ primary cutaneous lymphomas. Chemotherapy administration codes in the 96401–96434 range, transplant-related codes like 38240 and 38241, and radiation therapy codes in the 77261–77295 range all fall under this policy's scope.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Brentuximab Vedotin (Adcetris) — CPB 0823 |
| Policy Code | CPB 0823 |
| Change Type | Modified |
| Effective Date | February 25, 2026 |
| Impact Level | High |
| Specialties Affected | Hematology/Oncology, Radiation Oncology, Transplant, Pediatric Oncology, Dermatology (cutaneous lymphoma) |
| Key Action | Audit active Adcetris prior authorizations against updated indication and combination criteria before submitting new or renewal requests |
Aetna Brentuximab Vedotin Coverage Criteria and Medical Necessity Requirements 2026
The CPB 0823 Aetna system designates brentuximab vedotin as medically necessary for CD30+ disease — but CD30 positivity alone doesn't get you there. The specific indication, line of therapy, and combination regimen all factor into whether a claim gets paid or denied.
Precertification is required for every case. Call (866) 752-7021 or fax (888) 267-3277 to initiate. Aetna also applies a Site of Care Utilization Management policy to Adcetris, so the location where infusion is administered — not just the clinical criteria — affects coverage. If your patients are receiving infusions in higher-cost settings, check the site of care policy before assuming your prior authorization is sufficient.
Classic Hodgkin Lymphoma (cHL)
For CD30+ cHL, Aetna covers brentuximab vedotin in 12 distinct regimens. Single-agent use is covered. So is BV + AVD (doxorubicin, vinblastine, and dacarbazine), which is the standard frontline combination for advanced cHL. Re-induction and subsequent therapy regimens — including BV + bendamustine, BV + gemcitabine, and BV + ICE (ifosfamide, carboplatin, etoposide) — are covered for later lines.
Additional listed combinations include BrECADD (brentuximab with etoposide, cyclophosphamide, doxorubicin, dacarbazine, and dexamethasone), Bv-AVE-PC, AEPA, CAPDAC, and BV-CHP. That breadth of coverage across regimens is useful — but it also means your prior auth requests need to match the exact regimen name and components to avoid a coverage policy mismatch on review.
B-Cell Lymphomas (Non-Hodgkin Lymphoma)
For CD30+ B-cell lymphomas, coverage is limited to subsequent therapy lines — not first-line treatment. Covered subtypes include diffuse large B-cell lymphoma (DLBCL), high-grade B-cell lymphomas, post-transplant lymphoproliferative disorders (B-cell type), and HIV-related B-cell lymphomas including primary effusion lymphoma, HHV8-positive DLBCL, and plasmablastic lymphoma.
Pediatric primary mediastinal large B-cell lymphoma has a tighter bar. Coverage requires both relapsed or refractory disease AND combination with nivolumab or pembrolizumab. Miss either criterion in your medical necessity documentation and you're looking at a claim denial.
Primary Cutaneous Lymphomas
For CD30+ primary cutaneous lymphomas, mycosis fungoides (MF) and Sézary syndrome (SS) qualify for coverage. Lymphomatoid papulosis (LyP) coverage is more restricted: brentuximab vedotin must be used as a single agent and the disease must be relapsed or refractory. Document both conditions in your auth request.
Aetna Brentuximab Vedotin Exclusions and Non-Covered Indications
The policy's medical necessity criteria are indication-specific. Any use of brentuximab vedotin outside the listed CD30+ indications — or in a combination regimen not enumerated in CPB 0823 — will not meet Aetna's coverage criteria.
The real exposure here is combination regimens. The policy lists specific drug combinations with precision. If a treating oncologist uses a novel combination not on the list — even one supported by emerging clinical data — Aetna won't cover it under this policy. For off-label combinations under active clinical protocols, loop in your compliance officer before billing to understand your options on appeal.
First-line use in B-cell lymphoma subtypes is also not covered. The policy is explicit: those indications require subsequent therapy status. Document prior treatment lines carefully.
Coverage Indications at a Glance
| Indication | Status | Line of Therapy | Notes |
|---|---|---|---|
| CD30+ classic Hodgkin lymphoma — single agent | Covered | Any | Prior auth required |
| CD30+ cHL — BV + AVD (frontline) | Covered | First-line | Standard combo for advanced cHL |
| CD30+ cHL — BV + bendamustine | Covered | Re-induction / subsequent | |
| CD30+ cHL — BV + dacarbazine | Covered | Any | |
| CD30+ cHL — BV + nivolumab | Covered | Any | |
| CD30+ cHL — BV + gemcitabine | Covered | Re-induction / subsequent | |
| CD30+ cHL — BV + ICE | Covered | Subsequent | |
| CD30+ cHL — AEPA | Covered | Any | |
| CD30+ cHL — CAPDAC | Covered | Subsequent | |
| CD30+ cHL — Bv-AVE-PC | Covered | Any | |
| CD30+ cHL — BV-CHP | Covered | Any | |
| CD30+ cHL — BrECADD | Covered | Any | |
| CD30+ DLBCL | Covered | Subsequent only | Not covered first-line |
| CD30+ high-grade B-cell lymphoma | Covered | Subsequent only | |
| CD30+ post-transplant lymphoproliferative disorder (B-cell) | Covered | Subsequent only | |
| CD30+ HIV-related B-cell lymphomas (DLBCL, PEL, HHV8+ DLBCL, plasmablastic) | Covered | Subsequent only | |
| Pediatric CD30+ primary mediastinal large B-cell lymphoma | Covered | Relapsed/refractory only | Must combine with nivolumab or pembrolizumab |
| CD30+ mycosis fungoides / Sézary syndrome | Covered | Any | |
| CD30+ lymphomatoid papulosis | Covered | Relapsed/refractory only | Single agent only; both criteria required |
| Unlisted CD30+ indications | Not Covered | — | Off-label; appeal may be available |
| First-line B-cell lymphoma (non-cHL) | Not Covered | First-line | Policy restricts to subsequent therapy |
| LyP — combination regimen | Not Covered | Any | Policy requires single-agent use |
Aetna Brentuximab Vedotin Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Confirm CD30 positivity is documented before submitting any auth request. Every covered indication under CPB 0823 requires CD30+ disease. If the pathology report doesn't explicitly note CD30 positivity, the prior auth will fail. Pull the path report before your team submits. |
| 2 | Match your auth request to the exact regimen listed in CPB 0823. Aetna reviews combination regimens by component. "BV + AVD" and "BV + AVBD" are not the same in a payer review. Use the exact drug names and combinations listed in the policy when completing your Statement of Medical Necessity (SMN) form. |
| 3 | Document line of therapy for every B-cell lymphoma case. For DLBCL, high-grade B-cell lymphomas, post-transplant lymphoproliferative disorders, and HIV-related lymphomas, Aetna only covers subsequent-line use. Your auth request must show prior treatment history. A missing treatment history is a fast path to claim denial. |
| 4 | Check the Site of Care policy before scheduling infusions. Aetna's Utilization Management Policy on Site of Care for Specialty Drug Infusions applies to Adcetris reimbursement. If your patient is scheduled at a hospital outpatient department when a lower-cost setting is available, Aetna may not cover the infusion at that site — even if the drug itself is authorized. |
| 5 | Audit your brentuximab vedotin billing for claims submitted since February 25, 2026. The effective date is February 25, 2026. Any claims you submitted on or after that date should reflect the updated criteria. If your team used pre-modification auth language on post-effective-date claims, pull those and review them. Chemotherapy administration codes in the 96401–96434 range are the primary billing codes affected at the claim level. |
| 6 | For pediatric cases, verify both the indication and the regimen. CPB 0823 lists several combinations for cHL — including AEPA, CAPDAC, Bv-AVE-PC, and BrECADD — alongside separate criteria for pediatric primary mediastinal large B-cell lymphoma, which requires both relapsed/refractory status and combination with nivolumab or pembrolizumab. These are two different clinical scenarios with different criteria — don't conflate them in your documentation. |
| 7 | Use the correct precertification channel. Phone: (866) 752-7021. Fax: (888) 267-3277. SMN forms are on Aetna's Specialty Pharmacy Precertification page. If your team is using a third-party hub service to manage Adcetris auths, confirm they're submitting through these channels and not a general auth line. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Brentuximab Vedotin Under CPB 0823
Chemotherapy Administration CPT Codes
These are the primary codes your billing team uses to bill Adcetris infusions. All require that the underlying drug authorization is in place under CPB 0823.
| Code | Type | Description |
|---|---|---|
| 96401 | CPT | Chemotherapy administration code range |
| 96402 | CPT | Chemotherapy administration code range |
| 96403 | CPT | Chemotherapy administration code range |
| 96404 | CPT | Chemotherapy administration code range |
| 96405 | CPT | Chemotherapy administration code range |
| 96406 | CPT | Chemotherapy administration code range |
| 96407 | CPT | Chemotherapy administration code range |
| 96408 | CPT | Chemotherapy administration code range |
| 96409 | CPT | Chemotherapy administration code range |
| 96410 | CPT | Chemotherapy administration code range |
| 96411 | CPT | Chemotherapy administration code range |
| 96412 | CPT | Chemotherapy administration code range |
| 96413 | CPT | Chemotherapy administration code range |
| 96414 | CPT | Chemotherapy administration code range |
| 96415 | CPT | Chemotherapy administration code range |
| 96416 | CPT | Chemotherapy administration code range |
| 96417 | CPT | Chemotherapy administration code range |
| 96418 | CPT | Chemotherapy administration code range |
| 96419 | CPT | Chemotherapy administration code range |
| 96420 | CPT | Chemotherapy administration code range |
| 96421 | CPT | Chemotherapy administration code range |
| 96422 | CPT | Chemotherapy administration code range |
| 96423 | CPT | Chemotherapy administration code range |
| 96424 | CPT | Chemotherapy administration code range |
| 96425 | CPT | Chemotherapy administration code range |
| 96426 | CPT | Chemotherapy administration code range |
| 96427 | CPT | Chemotherapy administration code range |
| 96428 | CPT | Chemotherapy administration code range |
| 96429 | CPT | Chemotherapy administration code range |
| 96430 | CPT | Chemotherapy administration code range |
| 96431 | CPT | Chemotherapy administration code range |
| 96432 | CPT | Chemotherapy administration code range |
| 96433 | CPT | Chemotherapy administration code range |
| 96434 | CPT | Chemotherapy administration code range |
The policy data notes 16 additional CPT codes in this range not fully detailed in the provided data extract.
Transplant and Cell Therapy CPT Codes
These codes appear in CPB 0823 because brentuximab vedotin is used in disease contexts where transplant and CAR-T therapy are part of the overall treatment pathway.
| Code | Type | Description |
|---|---|---|
| 38204 | CPT | Management of recipient hematopoietic progenitor cell donor search and cell acquisition |
| 38205 | CPT | Blood-derived hematopoietic progenitor cell harvesting for transplantation — allogeneic |
| 38206 | CPT | Blood-derived hematopoietic progenitor cell harvesting for transplantation — autologous |
| 38225 | CPT | CAR-T therapy — harvesting of blood-derived T lymphocytes for development |
| 38226 | CPT | CAR-T therapy — preparation of blood-derived T lymphocytes for transportation |
| 38227 | CPT | CAR-T therapy — receipt and preparation of CAR-T cells for administration |
| 38228 | CPT | CAR-T cell administration, autologous |
| 38230 | CPT | Bone marrow harvesting for transplantation — allogeneic |
| 38232 | CPT | Bone marrow harvesting for transplantation — autologous |
| 38240 | CPT | Hematopoietic progenitor cell (HPC) — allogeneic transplantation per donor |
| 38241 | CPT | Hematopoietic progenitor cell (HPC) — autologous transplantation |
Radiation Therapy CPT Codes
| Code | Type | Description |
|---|---|---|
| 77261 | CPT | Radiation therapy |
| 77262 | CPT | Radiation therapy |
| 77263 | CPT | Radiation therapy |
| 77264 | CPT | Radiation therapy |
| 77265 | CPT | Radiation therapy |
| 77266 | CPT | Radiation therapy |
| 77267 | CPT | Radiation therapy |
| 77268 | CPT | Radiation therapy |
| 77269 | CPT | Radiation therapy |
| 77270 | CPT | Radiation therapy |
| 77271 | CPT | Radiation therapy |
| 77272 | CPT | Radiation therapy |
| 77273 | CPT | Radiation therapy |
| 77274 | CPT | Radiation therapy |
| 77275 | CPT | Radiation therapy |
| 77276 | CPT | Radiation therapy |
| 77277 | CPT | Radiation therapy |
| 77278 | CPT | Radiation therapy |
| 77279 | CPT | Radiation therapy |
| 77280 | CPT | Radiation therapy |
| 77281 | CPT | Radiation therapy |
| 77282 | CPT | Radiation therapy |
| 77283 | CPT | Radiation therapy |
| 77284 | CPT | Radiation therapy |
| 77285 | CPT | Radiation therapy |
| 77286 | CPT | Radiation therapy |
| 77287 | CPT | Radiation therapy |
| 77288 | CPT | Radiation therapy |
| 77289 | CPT | Radiation therapy |
| 77290 | CPT | Radiation therapy |
| 77291 | CPT | Radiation therapy |
| 77292 | CPT | Radiation therapy |
| 77293 | CPT | Radiation therapy |
| 77294 | CPT | Radiation therapy |
| 77295 | CPT | Radiation therapy |
HCPCS Codes
The source policy references 32 HCPCS codes that were not enumerated in the available data extract. Get the complete HCPCS code list directly from the full CPB 0823 policy on Aetna's provider portal before submitting claims.
Key ICD-10-CM Diagnosis Codes
The policy references 244 ICD-10-CM codes. The provided data extract did not include the complete code list. Pull the full CPB 0823 policy from Aetna's provider portal to get the complete ICD-10 code set before coding claims. Coding to an ICD-10 code outside Aetna's covered list is one of the most common sources of claim denial for specialty oncology drugs.
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