Idecabtagene Vicleucel (Abecma) — CPB 0992 | AETNA Coverage Update

Aetna modified CPB 0992 for idecabtagene vicleucel (Abecma), effective February 14, 2026. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its Abecma coverage policy under CPB 0992 in the Aetna system. This policy governs HCPCS code Q2055 and the full suite of CAR-T procedural codes—38225, 38226, 38227, and 38228—for relapsed or refractory multiple myeloma. If your practice or facility bills Abecma for commercial Aetna members, this updated policy defines exactly when you'll get paid and when you won't.

Quick-Reference Table

Aetna Abecma Coverage Criteria and Medical Necessity Requirements 2026

The Aetna Abecma coverage policy under CPB 0992 covers one dose of idecabtagene vicleucel (Q2055) for relapsed or refractory multiple myeloma. Coverage applies to members 18 and older. Every single one of the eight criteria below must be met—not most of them, all of them.

Criterion 1: Prior therapy lines. The member must have received at least two prior lines of therapy. Those lines must include at least one immunomodulatory agent (IMiD), at least one proteasome inhibitor, and at least one anti-CD38 monoclonal antibody. This is the triple-class exposure requirement.

Criterion 2: No prior CAR-T. The member cannot have received a prior course of Abecma or any other CAR-T cell therapy directed at any target. This isn't just BCMA-directed CAR-T—it's any CAR-T. One prior CAR-T infusion, regardless of target antigen, disqualifies the member under this coverage policy.

Criterion 3: ECOG performance status 0–2. Document this explicitly in the precertification request. An ECOG of 3 or 4 is a hard denial.

Criterion 4: Organ function. The member must have adequate and stable kidney, liver, pulmonary, and cardiac function. "Stable" is the operative word. Get current labs and cardiopulmonary assessments in the record before you call NME.

Criterion 5: CNS exclusions. This criterion is unusually detailed. Aetna excludes members with active or prior CNS involvement with myeloma, plus a long list of CNS conditions: epilepsy, seizure disorders, paresis, aphasia, stroke history, subarachnoid hemorrhage, CNS bleeds, severe brain injuries, dementia, Parkinson's disease, cerebellar disease, organic brain syndrome, and psychosis. The ICD-10 code set for this policy reflects that—it includes codes from G40 (epilepsy), G81 (hemiplegia), G20 (Parkinson's), F20–F29 (psychotic disorders), and the full dementia code range. If your patient has any of these in their problem list, flag it before submitting.

Criteria 6–8: Active conditions. The member cannot have a clinically significant active infection, active graft-versus-host disease, or an active inflammatory disorder. These are documentation-heavy exclusions. Your clinical team needs to attest to each one explicitly.

Prior authorization is non-negotiable here. This is a GCIT (Gene-based, Cellular & Other Innovative Therapies) product. Aetna routes all Abecma precertification through its National Medical Excellence (NME) program. Call 877-212-8811. Don't submit without it—you will not get reimbursement on the back end without prior authorization approval in place.

Aetna Abecma Exclusions and Non-Covered Indications

Aetna is explicit: all indications other than relapsed or refractory multiple myeloma meeting the eight criteria above are experimental, investigational, or unproven.

That includes any use in earlier lines of therapy for myeloma. Plasma cell leukemia is not listed as a covered indication under CPB 0992. It includes any off-label solid tumor application, despite the broad C00.0–C88.91 malignant tumor ICD-10 range appearing in the code set. Those codes are listed because they appear in the policy's diagnostic framework—they don't signal coverage. Don't read them as an invitation to bill for off-label use.

Any second infusion is also not covered under this policy. Abecma is approved for one dose. The policy says "one dose." There is no continuation of therapy pathway beyond dosage and administration guidance.

Coverage Indications at a Glance

Aetna Abecma Billing Guidelines and Action Items 2026

Abecma billing is among the most complex claim types your revenue cycle team handles. A claim denial on this drug is not a minor billing error. Work the checklist below before the effective date of February 14, 2026 catches you mid-authorization.

CPT, HCPCS, and ICD-10 Codes for Idecabtagene Vicleucel Under CPB 0992

Covered HCPCS Code (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes

The ICD-10 exclusion codes in this policy tell you something important. Aetna built out the full neurological and psychiatric exclusion code set. That's not accidental. Before you submit, run the patient's active problem list against G40, G81, G20, F20–F29, and the full dementia range. A matching code in the chart without a clinical explanation of why it doesn't disqualify the patient is a denial waiting to happen.