Lisocabtagene Maraleucel (Breyanzi) — CPB 0986 | AETNA Coverage Update

Aetna modified CPB 0986 for lisocabtagene maraleucel (Breyanzi), effective February 14, 2026. Here's what billing teams need to do.

Aetna, a CVS Health company, updated CPB 0986 — its coverage policy for lisocabtagene maraleucel (Breyanzi) — on February 14, 2026. This CAR-T cell therapy policy covers HCPCS code Q2054 and procedure codes 38225 through 38228 for the full CAR-T workflow, from T-cell harvesting to infusion. The update expands the covered indications and tightens the exclusion criteria that your precertification submissions must address.

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Field	Detail
Payer	Aetna, a CVS Health company
Policy	Lisocabtagene Maraleucel (Breyanzi) — CPB 0986
Policy Code	CPB 0986
Change Type	Modified
Effective Date	February 14, 2026
Impact Level	High
Specialties Affected	Hematology/Oncology, BMT programs, Hospital Outpatient, Infusion Centers
Key Action	Submit precertification through National Medical Excellence (NME) at 877-212-8811 before any Breyanzi infusion billed under Q2054

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Aetna Breyanzi Coverage Criteria and Medical Necessity Requirements 2026

The Aetna Breyanzi coverage policy designates Breyanzi as a GCIT® (Gene-based, Cellular & Other Innovative Therapies) product. That means dedicated review by the Aetna GCIT team — not a standard utilization management queue. Plan for longer review timelines and more detailed clinical documentation than you'd send for conventional chemotherapy.

Precertification is required. No exceptions for Aetna participating providers. Contact National Medical Excellence (NME) at 877-212-8811 before you harvest T-cells under CPT 38225. The prior authorization clock starts before the manufacturing process — not at infusion.

Adult B-Cell Lymphomas (Age 18+)

This is where most of your volume will fall. Aetna considers Breyanzi medically necessary for adult B-cell lymphomas in three distinct pathways:

Pathway 1 — Two or more prior lines of systemic therapy. The member must have relapsed or refractory disease and one of these subtypes:

Pathway 2 — First-line chemoimmunotherapy followed by relapsed/refractory disease. This is the second-line indication that expands Breyanzi's reach beyond heavily pretreated patients. Covered subtypes here include DLBCL, high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, HIV-related B-cell lymphomas, and monomorphic post-transplant lymphoproliferative disorder. Follicular lymphoma and marginal zone lymphoma are NOT covered under this pathway — only under Pathway 1.

Pathway 3 — Relapsed/refractory mantle cell lymphoma after a covalent BTK inhibitor. The member must have received prior treatment with acalabrutinib (Calquence), ibrutinib (Imbruvica), or zanobrutinib (Brukinsa). Note: the source policy lists "zanobrutinib" — verify against the full CPB 0986 text, as the standard drug name is zanubrutinib (Brukinsa). Document the specific BTK inhibitor, dates of therapy, and reason for discontinuation in your precertification package.

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

The policy summary was truncated at the CLL/SLL section, but this indication exists in CPB 0986. If your program treats CLL or SLL patients with Breyanzi, pull the full policy from Aetna's site before submitting. The medical necessity criteria for CLL/SLL likely include specific prior therapy requirements — don't assume the B-cell lymphoma pathways apply.

One-Dose Treatment Rule

Every indication in this coverage policy specifies "one dose treatment." Bill Q2054 once per treatment course. A second infusion — even for a different indication — will deny. Aetna explicitly excludes members who have received a previous treatment course with Breyanzi or any other CD19-directed CAR-T therapy.

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Aetna Breyanzi Exclusions and Non-Covered Indications

Aetna excludes members from Breyanzi coverage if any single exclusion criterion is met. This is an OR list — one disqualifier is enough for denial.

The ECOG exclusion is the one that gets overlooked most often. If your clinical team is considering Breyanzi for a debilitated patient, get the ECOG score in writing before you invest in precertification. A denial here wastes everyone's time — and delays care.

Active infections are a hard stop. Document infectious disease clearance explicitly. Don't assume an Aetna reviewer will infer it from lab values.

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Coverage Indications at a Glance

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Aetna Breyanzi Billing Guidelines and Action Items 2026

Lisocabtagene maraleucel billing is not standard oncology billing. The entire episode — from leukapheresis to infusion — runs through multiple CPT codes, and each step requires documentation that supports the original precertification.

Copy Action Items

If your program is new to CAR-T billing or you're seeing unexpected claim denials on this episode type, loop in your compliance officer and a billing consultant who specializes in cell therapy before the next submission.

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CPT, HCPCS, and ICD-10 Codes for Lisocabtagene Maraleucel Under CPB 0986

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
Q2054	HCPCS	Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures

CPT Codes Related to CPB 0986

The descriptions below for 96413–96417 are from the CPT code set, not from CPB 0986. The source policy lists all five codes as "Chemotherapy administration" without further detail. Verify against your current CPT manual.

Key ICD-10-CM Diagnosis Codes

The full policy includes 324 ICD-10-CM codes. Below are the diagnosis code ranges confirmed in the available policy data. Pull the complete list from the full CPB 0986 policy before finalizing your claims.

For DLBCL, mantle cell lymphoma, marginal zone lymphoma, CLL, and SLL diagnosis codes, refer to the full 324-code ICD-10 list in CPB 0986. These codes are not confirmed in the available policy excerpt. Do not bill a diagnosis code on assumption — a missing or mismatched code is a fast path to a claim denial.

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