Aetna Updates Lecanemab-irmb (Leqembi) Coverage Policy — CPB 1026 Effective March 2026

Aetna, a CVS Health company, has modified Clinical Policy Bulletin CPB 1026 governing coverage of lecanemab-irmb (Leqembi) for commercial medical plan members. This update refines the prior authorization requirements, medical necessity criteria, and exclusion criteria that determine whether an Alzheimer's disease patient qualifies for this high-cost amyloid-targeting biologic. Billing teams and revenue cycle directors at neurology, geriatric, and memory disorder practices need to review this policy carefully before submitting claims under HCPCS J0174.

Aetna Leqembi Coverage Criteria 2026 — What CPB 1026 Requires for Medical Necessity

Aetna considers lecanemab-irmb (Leqembi) medically necessary for Alzheimer's disease treatment only when a specific, multi-factor set of criteria is fully satisfied. Every element listed below is required — this is not a best-of or pick-one framework. A single unmet criterion is grounds for denial.

Age requirement: The member must be 50 years of age or older. Members under 50 may still qualify if they carry a documented genetic mutation in amyloid precursor protein (APP), presenilin-1 (PSEN1), or presenilin-2 (PSEN2), or have other clinical documentation supporting early-onset AD.

Clinical staging: The member must be at Clinical Stage 3 (cognitive impairment with early functional impact) or Clinical Stage 4 (dementia with mild functional impact). Stage 5 and beyond are not covered under this policy.

Cognitive assessment scores: Baseline cognitive impairment must be objectively documented using at least one of the following validated tools:

Amyloid confirmation: Members must have confirmed amyloid pathology via either a positive amyloid PET scan or an appropriate cerebrospinal fluid (CSF) profile consistent with AD. This is a hard requirement — clinical suspicion alone does not satisfy the standard.

Prescriber qualification: The medication must be prescribed by or in direct consultation with a geriatrician, neurologist, psychiatrist, or neuropsychiatrist. Scripts from primary care physicians without documented specialist consultation will not satisfy this requirement.

Aetna Leqembi Exclusion Criteria — Who Is Not Eligible

CPB 1026 is explicit: members meeting any of the following conditions are excluded from Leqembi coverage, regardless of how well they satisfy the positive criteria above.

• Suspected neurodegenerative etiology other than AD — including frontotemporal lobar degeneration (FTLD) or Lewy body disease without AD biomarker confirmation (positive amyloid PET or CSF profile)
• More than 4 cerebral microbleeds, cortical superficial siderosis, or major vascular cognitive impairment confirmed on MRI
• Cerebral contusion, encephalomalacia, brain aneurysm or other vascular malformation, CNS infection, or brain tumor
• History of TIA, stroke, uncontrolled hypertension, or seizures within the past 12 months
• Bleeding disorder not under adequate control — specifically a platelet count below 50,000 or INR greater than 1.5
• Immunologic disorder requiring immunoglobulins, monoclonal antibodies, immunosuppressants, or plasmapheresis

Additionally, Leqembi will not be approved for concurrent use with any other amyloid beta-directed antibodies, including aducanumab or donanemab.

Prior Authorization Requirements for Aetna Leqembi Claims

Precertification is required for all Aetna participating providers and members in applicable plan designs. There is no exception pathway. Contact Aetna using the channels below before initiating treatment:

• Phone: (866) 752-7021
• Fax: (888) 267-3277
• SMN Forms: Available via Aetna's Specialty Pharmacy Precertification portal

Aetna's Site of Care Utilization Management Policy also applies to Leqembi. Because this drug is administered by IV infusion, site-of-service rules govern whether the infusion can be performed in a hospital outpatient setting, physician office, or home infusion setting. Review Aetna's Utilization Management Policy on Site of Care for Specialty Drug Infusions before scheduling the first infusion — the wrong site of service is a common and preventable denial driver for high-cost biologics.

Affected Codes

Covered HCPCS Code (if selection criteria are met)

Diagnostic & Imaging CPT Codes Referenced in CPB 1026

Infusion Administration CPT Codes

Amyloid PET Radiopharmaceutical HCPCS Codes

Key ICD-10-CM Diagnosis Codes

What Your Billing Team Should Do