Aetna modified CPB 0920 covering tisagenlecleucel (Kymriah) CAR-T therapy, effective February 25, 2026. Here's what billing teams need to know.
Aetna, a CVS Health company, updated its Kymriah coverage policy under CPB 0920 Aetna as of February 25, 2026. This policy governs Q2042 (the primary HCPCS billing code for tisagenlecleucel) and CPT codes 38225–38228 for the full CAR-T cell therapy workflow—from T-cell harvesting through administration. If your team bills for CAR-T services under commercial Aetna plans, this update sets the criteria that will determine approval or claim denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Tisagenlecleucel (Kymriah) — CPB 0920 |
| Policy Code | CPB 0920 |
| Change Type | Modified |
| Effective Date | February 25, 2026 |
| Impact Level | High |
| Specialties Affected | Hematology/Oncology, Pediatric Oncology, Bone Marrow Transplant Programs, Hospital Outpatient |
| Key Action | Verify all precertification requests go through National Medical Excellence (NME) at 1-877-212-8811 before scheduling leukapheresis |
Aetna Kymriah Coverage Criteria and Medical Necessity Requirements 2026
Kymriah tisagenlecleucel billing starts with one non-negotiable: precertification through Aetna's National Medical Excellence program. Call NME at 1-877-212-8811 before any step in the CAR-T process begins. Skip that call and you're looking at a claim denial regardless of how well the member fits the clinical criteria.
Aetna routes all Kymriah requests—commercial and Medicare—through its Gene-based, Cellular & Other Innovative Therapies (GCIT) team. That's a specialized review unit, not standard UM. Build that into your timeline when planning prior authorization submissions.
The coverage policy splits into two distinct patient populations. Get the population wrong and the criteria don't apply.
Pediatric and Young Adult B-cell ALL (Under 26 Years)
For B-cell precursor ALL in members under 26, Aetna requires all of the following:
| # | Covered Indication |
|---|---|
| 1 | CD19 tumor expression confirmed in bone marrow or peripheral blood |
| 2 | At least 5% lymphoblasts in the bone marrow |
| 3 | Performance status: Karnofsky score ≥50% (age ≥16) or Lansky score ≥50% (age <16) |
| 4 | Disease status must meet one of two paths: |
Philadelphia chromosome-negative disease: Member must be refractory or have had two or more relapses.
Philadelphia chromosome-positive disease: Member must meet at least one of these—refractory disease, two or more relapses with failure of at least two TKIs (asciminib, bosutinib, dasatinib, imatinib, nilotinib, or ponatinib), relapsed disease with TKI intolerance, or relapse post-hematopoietic stem cell transplant (HSCT).
This is a single-dose treatment. Document it as such when billing Q2042.
Adult B-cell Lymphomas (18 Years and Older)
For adult B-cell lymphoma, Aetna covers Kymriah when all of these conditions are met:
| # | Covered Indication |
|---|---|
| 1 | Member has one of the covered subtypes (see the Coverage Indications table below) |
| 2 | Member has received two or more prior lines of systemic therapy |
| 3 | Member does not have primary central nervous system lymphoma |
| 4 | Member has an ECOG performance status of 0 to 2 |
The ECOG performance status requirement is a hard stop. An ECOG of 3 or 4 disqualifies the member under this coverage policy. Document the ECOG score in your prior authorization submission.
Medical necessity documentation must match the specific subtype. DLBCL arising from follicular lymphoma, follicular lymphoma itself, HIV-related B-cell lymphomas, and monomorphic post-transplant lymphoproliferative disorders (B-cell type) are all separately enumerated. Use the right ICD-10-CM code for the specific subtype—don't default to a generic lymphoma code and expect the claim to process cleanly.
Aetna Kymriah Exclusions and Non-Covered Indications
Aetna excludes members from Kymriah eligibility if any one of the following applies. One exclusion disqualifies the member—these aren't weighted.
| # | Excluded Procedure |
|---|---|
| 1 | Prior CAR-T therapy: Any previous course of Kymriah or another CD19-directed CAR-T therapy. This is a lifetime limit built into the policy. |
| 2 | Organ function: Inadequate or unstable kidney, liver, pulmonary, or cardiac function. |
| 3 | Infection: Active or latent hepatitis B, active hepatitis C, or any active uncontrolled infection. |
| 4 | Active graft versus host disease (GVHD) |
| 5 | Active inflammatory disorder |
The hepatitis B exclusion is worth flagging explicitly. Latent hepatitis B—not just active—disqualifies the member. Make sure your prior authorization documentation includes hepatitis B serology. If the member has a latent infection that's being managed, document that discussion with the GCIT team before submission.
The prior CAR-T exclusion closes a door permanently. A member who received axicabtagene ciloleucel (another CD19-directed therapy) is not eligible for Kymriah under this policy. Reimbursement won't follow a re-treatment request.
Coverage Indications at a Glance
| Indication | Status | Key Codes | Notes |
|---|---|---|---|
| B-cell precursor ALL, Ph-negative, refractory or ≥2 relapses, age <26 | Covered | Q2042, 38225–38228 | CD19+, ≥5% lymphoblasts, performance status ≥50% required |
| B-cell precursor ALL, Ph-positive, refractory, age <26 | Covered | Q2042, 38225–38228 | CD19+, ≥5% lymphoblasts, performance status ≥50% required |
| B-cell precursor ALL, Ph-positive, ≥2 relapses + ≥2 TKI failures, age <26 | Covered | Q2042, 38225–38228 | TKI list: asciminib, bosutinib, dasatinib, imatinib, nilotinib, ponatinib |
| B-cell precursor ALL, Ph-positive, TKI-intolerant, relapsed, age <26 | Covered | Q2042, 38225–38228 | Document intolerance reason in PA submission |
| B-cell precursor ALL, Ph-positive, post-HSCT relapse, age <26 | Covered | Q2042, 38225–38228 | — |
| DLBCL (including arising from follicular lymphoma), age ≥18 | Covered | Q2042, 38225–38228 | ≥2 prior lines of systemic therapy, ECOG 0–2, no primary CNS lymphoma |
| Follicular lymphoma, age ≥18 | Covered | Q2042, 38225–38228 | ≥2 prior lines of systemic therapy, ECOG 0–2 |
| High-grade B-cell lymphoma (double/triple hit), age ≥18 | Covered | Q2042, 38225–38228 | ≥2 prior lines of systemic therapy, ECOG 0–2 |
| HIV-related B-cell lymphomas (DLBCL, primary effusion lymphoma, plasmablastic, HHV8+), age ≥18 | Covered | Q2042, 38225–38228 | ≥2 prior lines of systemic therapy, ECOG 0–2 |
| Monomorphic post-transplant lymphoproliferative disorder (B-cell type), age ≥18 | Covered | Q2042, 38225–38228 | ≥2 prior lines of systemic therapy, ECOG 0–2 |
| Histologic transformation of indolent lymphoma to DLBCL, age ≥18 | Covered | Q2042, 38225–38228 | ≥2 prior lines of systemic therapy, ECOG 0–2 |
| Primary CNS lymphoma | Not Covered | — | Explicit exclusion for adult lymphoma indication |
| Prior CD19-directed CAR-T therapy (any) | Not Covered | — | Lifetime exclusion; no re-treatment permitted |
| Active GVHD, active inflammatory disorder, active uncontrolled infection | Not Covered | — | Any one excludes the member |
| Latent or active hepatitis B; active hepatitis C | Not Covered | — | Latent HBV counts as an exclusion |
Aetna Kymriah Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Contact NME before scheduling leukapheresis. Call 1-877-212-8811. Precertification is required for all Aetna participating providers under all applicable plan designs. If you schedule before you have authorization, you own the financial risk. The effective date for these criteria is February 25, 2026. |
| 2 | Bill Q2042 as the primary HCPCS code for the tisagenlecleucel product. The descriptor covers up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation. Confirm with your billing consultant how leukapheresis should be billed in relation to Q2042—the code description references leukapheresis, and separate billing may create a bundling issue depending on your payer contract and claim adjudication rules. |
| 3 | Use CPT 38225–38228 in sequence to capture the full CAR-T workflow. CPT 38225 covers T-cell harvesting. CPT 38226 covers preparation of blood-derived T lymphocytes for transportation. CPT 38227 covers receipt and preparation of CAR-T cells for administration. CPT 38228 covers autologous CAR-T cell administration. Each step is a separate billable service—don't compress them. |
| 4 | Match your ICD-10-CM code to the specific lymphoma subtype. Aetna's coverage policy is subtype-specific for adult lymphoma. Billing a generic lymphoma code when the member has HIV-related DLBCL or a double-hit high-grade B-cell lymphoma invites a medical necessity denial. Pull the right code from the policy's ICD-10 list before submission. |
| 5 | Confirm ECOG and performance status documentation is in the chart before PA submission. For adults, ECOG 0–2 is a hard requirement. For pediatric patients, Karnofsky ≥50% (age ≥16) or Lansky ≥50% (age <16) is required. The GCIT review team will look for this. Missing documentation is the fastest path to a prior authorization denial. |
| 6 | Verify hepatitis B serology—including latent status—before submission. Active or latent hepatitis B excludes the member. If your oncology team is managing a latent infection with antiviral prophylaxis, that clinical context needs to be addressed with the GCIT team before you submit. Don't assume prophylaxis treatment resolves the exclusion. |
| 7 | Flag re-treatment requests immediately. Any member who has previously received Kymriah or any other CD19-directed CAR-T therapy is excluded. If a case manager or physician asks about re-treatment, escalate to your compliance officer before submitting. The denial will come fast and the appeal path is narrow under this coverage policy. |
If you're billing for a high-volume CAR-T program, talk to your compliance officer and a billing consultant who specializes in cell therapy before the February 25, 2026 effective date. The dollar exposure per case is too high to sort out through trial and error.
| 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 Tisagenlecleucel Under CPB 0920
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 38225 | CPT | Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for deve[scription truncated in source] |
| 38226 | CPT | Preparation of blood-derived T lymphocytes for transportation (e.g., cryopreservation, storage) |
| 38227 | CPT | Receipt and preparation of CAR-T cells for administration |
| 38228 | CPT | CAR-T cell administration, autologous |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| Q2042 | HCPCS | Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation [description truncated in source] |
Other CPT Codes Related to the CPB
These codes appear in the policy as "Other CPT codes related to the CPB." The source policy does not assign a covered or non-covered status to these codes. Bill only when clinically appropriate and separately documented.
| Code | Type | Description |
|---|---|---|
| 96365 | CPT | Intravenous infusion administration |
| 96366 | CPT | Intravenous infusion administration |
| 96367 | CPT | Intravenous infusion administration |
| 96368 | CPT | Intravenous infusion administration |
| 96413 | CPT | Intravenous chemotherapy administration |
| 96414 | CPT | Intravenous chemotherapy administration |
| 96415 | CPT | Intravenous chemotherapy administration |
| 96416 | CPT | Intravenous chemotherapy administration |
| 96417 | CPT | Intravenous chemotherapy administration |
Key ICD-10-CM Diagnosis Codes
The full policy references 347 ICD-10-CM codes. Below are the primary diagnosis codes listed in the source for the C71.x range. Use the most specific code available.
| Code | Description |
|---|---|
| C71.0 | Malignant neoplasm of the brain |
| C71.1 | Malignant neoplasm of the brain |
| C71.2 | Malignant neoplasm of the brain |
| C71.3 | Malignant neoplasm of the brain |
| C71.4 | Malignant neoplasm of the brain |
| C71.5 | Malignant neoplasm of the brain |
| C71.6 | Malignant neoplasm of the brain |
| C71.7 | Malignant neoplasm of the brain |
| C71.8 | Malignant neoplasm of the brain |
| C71.9 | Malignant neoplasm of the brain |
The policy's full ICD-10-CM list includes 347 codes. Pull the complete list from CPB 0920 on PayerPolicy to confirm covered diagnosis codes for your specific patient population.
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