Ciltacabtagene Autoleucel (Carvykti) — CPB 1007 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 1007 covering ciltacabtagene autoleucel (Carvykti), effective February 14, 2026. Billing teams need to verify all nine medical necessity criteria before submitting claims under HCPCS Q2056 and CAR-T procedure codes 38225–38228.

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Aetna updated its Carvykti coverage policy under CPB 1007 Aetna system, tightening the criteria framework for this high-cost CAR-T therapy used in relapsed or refractory multiple myeloma. The policy governs HCPCS code Q2056 (ciltacabtagene autoleucel) alongside CPT codes 38225, 38226, 38227, and 38228 for the full CAR-T workflow—from T-cell harvesting through infusion. If your oncology or hematology billing team handles Carvykti cases, this policy warrants a close read before you submit another claim.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Ciltacabtagene Autoleucel (Carvykti) — CPB 1007
Policy Code	CPB 1007
Change Type	Modified
Effective Date	February 14, 2026
Impact Level	High
Specialties Affected	Hematology, Oncology, Bone Marrow Transplant Programs, Infusion Centers
Key Action	Confirm all nine medical necessity criteria are documented before submitting Q2056 claims; contact NME at 877-212-8811 for precertification

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Aetna Ciltacabtagene Autoleucel Coverage Criteria and Medical Necessity Requirements 2026

Aetna's Carvykti coverage policy requires prior authorization through the National Medical Excellence (NME) program. Call 877-212-8811 before you schedule leukapheresis. This is not optional—precertification is required for all Aetna participating providers and members in applicable plan designs. If you skip this step, you own the denial.

The coverage policy designates Carvykti as a GCIT product—Gene-based, Cellular & Other Innovative Therapies. That designation means Aetna's dedicated GCIT team reviews these cases, not the standard medical review queue. Expect more scrutiny, longer turnaround times, and a higher documentation bar than you'd see on a typical oncology prior auth.

To establish medical necessity for Q2056, your clinical team must satisfy all nine criteria below. Every one of them must be met. Missing a single criterion means a denial.

The nine criteria for medical necessity:

Criteria nine bundles four separate exclusionary conditions into one line. Document each of those four conditions explicitly in your precertification request. Don't leave the GCIT reviewer to infer that the patient is free of CNS disease—state it directly in the clinical notes. Note that the CNS exclusion covers both active CNS involvement and prior history of CNS involvement. Both disqualify the member.

The lenalidomide-refractory requirement (criterion five) is worth flagging to your clinical documentation team now. The policy requires lenalidomide-refractory disease; ensure the oncologist's documentation explicitly states refractory status. The policy does not define the refractory window—work with your clinical team and reference FDA labeling or NCCN guidelines for documentation standards, but do not represent a specific timeframe as Aetna policy.

Carvykti billing under this coverage policy is a one-dose treatment. The policy explicitly states "one dose" in the medical necessity section. Continuation-of-therapy provisions refer back to dosage and administration guidance, not to repeated infusions.

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Aetna Carvykti Exclusions and Non-Covered Indications

Aetna's position is direct: all other indications are experimental, investigational, or unproven. Carvykti has one covered indication under this policy—relapsed or refractory multiple myeloma in adults who meet all nine criteria above.

Any use outside that box—pediatric patients, earlier lines of therapy, solid tumors, other hematologic malignancies—will be denied as experimental. Don't submit Q2056 for off-label indications expecting to win on appeal. Aetna has locked this down firmly.

The CAR-T exclusivity requirement (criterion six) is also a hard wall. If your patient received any prior CAR-T therapy—idecabtagene vicleucel, lisocabtagene maraleucel, or any other product directed at any antigen—Carvykti is not covered. This isn't BCMA-specific. It's any CAR-T, any target, ever.

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Coverage Indications at a Glance

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Aetna Carvykti Billing Guidelines and Action Items 2026

The financial exposure on Carvykti claims is significant. Carvykti carries a list price well above $400,000 per infusion. A denial on Q2056 without a solid appeal strategy is not a recoverable situation for most practices. Get your process right before the effective date of February 14, 2026.

Copy Action Items

If you're not sure how the GCIT review process applies to your Carvykti volume, talk to your compliance officer before submitting new cases. The reimbursement stakes are too high to learn through denials.

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CPT, HCPCS, and ICD-10 Codes for Ciltacabtagene Autoleucel Under CPB 1007

HCPCS Codes — Covered When Selection Criteria Are Met

Code	Type	Description Copy
Q2056	HCPCS	Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen (BCMA)-directed CAR-T cells

CPT and HCPCS Codes — Related to CPB 1007

These codes cover the full CAR-T workflow and associated therapies billed in connection with Carvykti treatment.

Key ICD-10-CM Diagnosis Codes

For the primary Carvykti indication, bill C90.0 (multiple myeloma [relapsed or refractory]) as listed in the source policy. Verify the correct code specificity with your clinical team and coding resources at each encounter.

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