Aetna Updates Breyanzi (Lisocabtagene Maraleucel) Coverage Policy CPB 0986 — What Billing Teams Need to Know

Aetna, a CVS Health company, has modified Clinical Policy Bulletin CPB 0986 governing coverage of lisocabtagene maraleucel (Breyanzi), effective March 12, 2026. This CAR-T cell therapy policy covers a broad range of B-cell malignancies, chronic lymphocytic leukemia (CLL), and small lymphocytic lymphoma (SLL), and carries strict prior authorization requirements through Aetna's dedicated Gene-based, Cellular & Other Innovative Therapies (GCIT®) review team. Revenue cycle teams at oncology practices and infusion centers billing HCPCS Q2054 need to review updated eligibility criteria before submitting any precertification requests.

Aetna Breyanzi Coverage Criteria 2026: What Changed in CPB 0986

Breyanzi is classified under Aetna's GCIT® program, meaning every authorization request—commercial and Medicare—routes to a specialized review team rather than standard utilization management. That distinction matters: standard PA workflows won't apply here. All participating Aetna providers must contact National Medical Excellence (NME) at 877-212-8811 to initiate precertification. There is no exception for any plan design where Breyanzi is a covered benefit.

The updated policy reflects the therapy's expanding FDA-approved indications and real-world clinical use. Billing teams should treat this as a full re-review of criteria, not a minor administrative update.

Aetna Breyanzi Medical Necessity Criteria: Who Qualifies

Adult B-Cell Lymphomas (Age 18+)

Aetna considers Breyanzi medically necessary for adult B-cell lymphoma patients under three distinct clinical pathways:

Pathway 1 — Two or more prior lines of systemic therapy with any of the following diagnoses:

• Diffuse large B-cell lymphoma (DLBCL), including DLBCL NOS, follicular lymphoma grade 3, and DLBCL arising from indolent lymphomas
• High-grade B-cell lymphoma (including double/triple hit lymphoma with MYC and BCL2/BCL6 translocations)
• Primary mediastinal large B-cell lymphoma
• Follicular lymphoma
• Marginal zone lymphoma
• HIV-related B-cell lymphomas (including primary effusion lymphoma, HHV8-positive DLBCL NOS, and plasmablastic lymphoma)
• Monomorphic post-transplant lymphoproliferative disorder (B-cell type)

Pathway 2 — Relapsed/refractory disease after first-line chemoimmunotherapy with any of the following:

• DLBCL (including NOS, grade 3 follicular, and indolent-derived)
• High-grade B-cell lymphoma
• Primary mediastinal large B-cell lymphoma
• HIV-related B-cell lymphomas
• Monomorphic post-transplant lymphoproliferative disorder (B-cell type)

Pathway 3 — Relapsed/refractory mantle cell lymphoma after prior treatment with a covalent Bruton tyrosine kinase (BTK) inhibitor. Covered BTK inhibitors referenced in the policy include acalabrutinib (Calquence), ibrutinib (Imbruvica), and zanubrutinib (Brukinsa).

Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)

The policy also addresses CLL/SLL indications—review the full CPB 0986 text for complete criteria, as this section was truncated in the source document. Confirm current criteria directly at the Aetna CPB 0986 source before submitting any CLL/SLL authorization.

Aetna Breyanzi Exclusions: Who Does NOT Qualify

Aetna will deny coverage if any of the following conditions apply—these are hard exclusions, not rebuttable with clinical documentation:

1. Primary central nervous system lymphoma
2. Previous treatment with Breyanzi or any other CD19-directed CAR-T cell therapy
3. ECOG performance status ≥ 3
4. Inadequate or unstable kidney, liver, pulmonary, or cardiac function
5. Active hepatitis B or hepatitis C
6. Any active uncontrolled infection
7. Active graft versus host disease
8. Active inflammatory disorder

The re-treatment exclusion is particularly significant for billing teams: if a patient has received any prior CD19-directed CAR-T—not just Breyanzi—they are categorically ineligible under this policy. Document the patient's CAR-T treatment history explicitly in precertification requests.

Affected Codes

Covered HCPCS Code

Representative ICD-10-CM Diagnosis Codes

The full policy references 324 ICD-10-CM codes. Key covered diagnosis codes include:

Note that codes spanning A00.0–B99.9 (certain infectious and parasitic diseases) appear in the policy as exclusion indicators—active uncontrolled infections in this range support denial. Verify the complete ICD-10 list in the full policy document before coding.

What Your Billing Team Should Do