Aetna modified CPB 1007 for ciltacabtagene autoleucel (Carvykti), effective February 14, 2026. Here's what billing teams need to do.
Aetna updated its Carvykti coverage policy under CPB 1007, effective February 14, 2026. The primary HCPCS code for this therapy is Q2056, and the CAR-T procedure codes 38225 through 38228 are also in scope. If your team bills for hematology-oncology services or manages a cancer center's revenue cycle, this update deserves your full attention before claims go out.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Ciltacabtagene Autoleucel (Carvykti) — CPB 1007 |
| Policy Code | CPB 1007 |
| Change Type | Modified |
| Effective Date | 2026-02-14 |
| Impact Level | High |
| Specialties Affected | Hematology, Oncology, Bone Marrow Transplant Programs, Hospital Outpatient |
| Key Action | Confirm all nine medical necessity criteria are documented before submitting precertification through NME at 877-212-8811 |
Aetna Carvykti Coverage Criteria and Medical Necessity Requirements 2026
Aetna Carvykti coverage policy under CPB 1007 covers one dose of ciltacabtagene autoleucel for adults 18 and older with relapsed or refractory multiple myeloma. Coverage is not automatic. Every single one of nine criteria must be met — and Aetna will look at all of them during precertification review.
Start with the treatment history requirement. The member must have received at least one prior line of therapy that included both an immunomodulatory agent (think lenalidomide, pomalidomide, or thalidomide) and a proteasome inhibitor (bortezomib billed as J9041, J9044, J9046, J9048, J9049, or J9051 — or carfilzomib billed as J9047). Both drug classes must appear in the treatment history. One without the other is a denial.
The disease must also be lenalidomide-refractory. Documented progression on or after lenalidomide therapy is not optional clinical detail — it is a hard coverage criterion. Pull the oncologist's records and make sure this language appears explicitly before you submit.
The CAR-T naïve requirement is strict. The member cannot have received Carvykti before, and cannot have received any other CAR-T therapy directed at any target. This includes idecabtagene vicleucel (Abecma), which also targets BCMA. If your patient had prior CAR-T treatment of any kind, this claim will not pass medical necessity review.
Performance status matters too. The member needs an ECOG performance status of 0 to 2. Make sure the treating physician documents this score explicitly in the chart — not just a narrative description of functional status.
The remaining criteria are exclusionary. Aetna will deny coverage if the member has any of the following:
| # | Covered Indication |
|---|---|
| 1 | Inadequate or unstable kidney, liver, pulmonary, or cardiac function |
| 2 | Known active or prior history of CNS involvement, including CNS multiple myeloma |
| 3 | Clinically significant active infection |
| 4 | Active graft versus host disease |
| 5 | Active inflammatory disorder |
Each of these requires documented evaluation. Gaps in any one area create a denial risk. The prior authorization submission to National Medical Excellence (NME) at 877-212-8811 needs to address all nine criteria — not just the ones your team considers obvious.
The Carvykti billing guidelines also require noting that Aetna designates this as a GCIT (Gene-based, Cellular & Other Innovative Therapies) product. This means dedicated review by Aetna's GCIT team, not standard utilization management. Build extra lead time into your precertification workflow for that process.
Aetna Carvykti Exclusions and Non-Covered Indications
Aetna's coverage policy is explicit on this: all indications other than the one described above are experimental, investigational, or unproven.
Carvykti is not covered for:
| # | Excluded Procedure |
|---|---|
| 1 | Newly diagnosed multiple myeloma (even high-risk disease) |
| 2 | Any solid tumor indication |
| 3 | Any hematologic malignancy other than relapsed or refractory multiple myeloma meeting all nine criteria |
| 4 | Patients with prior CAR-T therapy of any kind |
| 5 | Patients under 18 years of age |
| 6 | Any second dose — the coverage policy authorizes one dose only |
If a provider submits a claim for Carvykti in a newly diagnosed patient, or for a second infusion, expect a claim denial. Document your coverage check before the treatment plan is finalized, not after the cells are already manufactured.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Relapsed or refractory multiple myeloma, 18+, meeting all nine criteria | Covered | Q2056, 38225–38228, C90.0 | One dose only; prior auth required via NME 877-212-8811; GCIT dedicated review |
| Multiple myeloma — prior CAR-T therapy (any target) | Not Covered | Q2056 | Hard exclusion; no exceptions noted |
| Newly diagnosed multiple myeloma | Not Covered | Q2056 | Must have prior treatment history with IMiD + PI |
| Second or subsequent Carvykti dose | Not Covered | Q2056 | Policy authorizes one dose only |
| Any other hematologic malignancy | Experimental/Unproven | Q2056 | All other indications excluded |
| Solid tumors | Experimental/Unproven | Q2056 | ICD-10 C00.0–C88.91 range not covered under this policy |
| CNS multiple myeloma | Not Covered | Q2056 | Active or prior CNS involvement is an exclusion criterion |
Aetna Carvykti Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Call NME before the apheresis appointment. Precertification is required for all Aetna participating providers and members in applicable plan designs. The number is 877-212-8811. Don't wait until infusion day — CAR-T manufacturing takes weeks, and a precertification gap discovered late means a manufactured product and a denial. |
| 2 | Build a documentation checklist for all nine criteria. Create a pre-submission checklist that maps each of the nine medical necessity criteria to a specific document in the chart. Treatment history with IMiD and proteasome inhibitor, lenalidomide-refractory documentation, CAR-T naïve confirmation, ECOG score, organ function labs, CNS status, infection screening, GvHD status, and inflammatory disorder screening. All nine. Every time. |
| 3 | Bill Q2056 for the Carvykti product itself. Q2056 is the covered HCPCS code for ciltacabtagene autoleucel, up to 100 million autologous BCMA-directed CAR-T cells. This is the code Aetna recognizes for reimbursement under this coverage policy. Make sure your charge capture maps Q2056 correctly before the effective date of February 14, 2026. |
| 4 | Bill the CAR-T procedure codes in the correct sequence. CPT 38225 covers harvesting of blood-derived T lymphocytes. CPT 38226 covers preparation and cryopreservation for transport. CPT 38227 covers receipt and preparation of CAR-T cells at the infusion site. CPT 38228 covers the actual autologous CAR-T cell administration. These are sequential — bill them in order and match them to the correct service dates. |
| 5 | Use the chemotherapy administration codes for lymphodepleting conditioning. CPT codes 96413, 96414, 96415, 96416, and 96417 cover IV chemotherapy infusion. Lymphodepleting conditioning given before Carvykti infusion bills under these codes. Confirm your facility is capturing these separately and correctly — they represent real revenue and are often missed in CAR-T billing workflows. |
| 6 | Verify the prior treatment HCPCS codes appear in the treatment history. Aetna reviewers will look for documented prior treatment with a proteasome inhibitor. If bortezomib was used, the billing record should reflect J9041 (or the applicable biosimilar codes J9044, J9046, J9048, J9049, J9051). Carfilzomib bills as J9047. Daratumumab (J9145) may also appear in the treatment history. These are the "other HCPCS codes related to the CPB" — they won't appear on your Carvykti claim, but they need to be documentable from prior claims or records. |
| 7 | Use C90.0 for the primary diagnosis. The source policy lists C90.0 (multiple myeloma, relapsed or refractory) as the primary covered ICD-10-CM code. Confirm with your coding team which sub-level code matches the clinical documentation — sub-level specificity (such as C90.00, C90.01, or C90.02) reflects standard ICD-10 coding practice, but those specific codes are not enumerated in Aetna's CPB 1007 source policy. Code to the level your clinical documentation supports. |
| 8 | Loop in your compliance officer if your program sees edge cases. CAR-T therapy generates some of the highest per-claim dollar amounts in oncology billing. If you're unsure how Aetna will interpret a patient's prior treatment history or performance status documentation, talk to your compliance officer or billing consultant before the effective date — not after a denial lands. |
| 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 Ciltacabtagene Autoleucel (Carvykti) Under CPB 1007
Covered HCPCS Code (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| Q2056 | HCPCS | Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen (BCMA) directed CAR-T cells |
CAR-T Procedure CPT Codes
| Code | Type | Description |
|---|---|---|
| 38225 | CPT | CAR-T therapy; harvesting of blood-derived T lymphocytes for development of genetically modified CAR-T cells |
| 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 |
Chemotherapy Administration CPT Codes
| Code | Type | Description |
|---|---|---|
| 96413 | CPT | Chemotherapy administration, intravenous infusion technique; up to 1 hour |
| 96414 | CPT | Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion |
| 96415 | CPT | Chemotherapy administration, intravenous infusion technique; each additional hour |
| 96416 | CPT | Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump |
| 96417 | CPT | Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug) |
Prior Treatment HCPCS Codes (Related to CPB — Not the Carvykti Claim)
| Code | Type | Description |
|---|---|---|
| J9041 | HCPCS | Injection, bortezomib, 0.1 mg |
| J9044 | HCPCS | Injection, bortezomib, not otherwise specified, 0.1 mg |
| J9046 | HCPCS | Injection, bortezomib (Dr. Reddy's), not therapeutically equivalent to J9041, 0.1 mg |
| J9047 | HCPCS | Injection, carfilzomib, 1 mg |
| J9048 | HCPCS | Injection, bortezomib (Fresenius Kabi), not therapeutically equivalent to J9041, 0.1 mg |
| J9049 | HCPCS | Injection, bortezomib (Hospira), not therapeutically equivalent to J9041, 0.1 mg |
| J9051 | HCPCS | Injection, bortezomib (Maia), not therapeutically equivalent to J9041, 0.1 mg |
| J9145 | HCPCS | Injection, daratumumab, 10 mg |
ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| C90.0 | Multiple myeloma [relapsed or refractory] |
| C90.1 | Multiple myeloma [relapsed or refractory] |
| C90.10 | Plasma cell leukemia not having achieved remission |
| C90.2 | Multiple myeloma [relapsed or refractory] |
| C90.20 | Malignant solid tumors |
| C90.21 | Malignant solid tumors |
| C90.22 | Malignant solid tumors |
| C90.23 | Malignant solid tumors |
| C90.24 | Malignant solid tumors |
| C90.25 | Malignant solid tumors |
| C90.26 | Malignant solid tumors |
| C90.27 | Malignant solid tumors |
| C90.28 | Malignant solid tumors |
| C90.29 | Malignant solid tumors |
| C90.30 | Malignant solid tumors |
| C90.31 | Malignant solid tumors |
| C90.32 | Malignant solid tumors |
| C96.0–D09.9 | Other malignant neoplasms (related range) |
| C00.0–C88.91 | Malignant solid tumors (referenced in policy — excluded indications) |
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