Aetna modified CPB 1026 for lecanemab-irmb (Leqembi), effective January 29, 2026. Here's what billing teams need to do.
Aetna, a CVS Health company, updated its lecanemab-irmb (Leqembi) coverage policy under CPB 1026 Aetna system on January 29, 2026. This update defines the full medical necessity criteria, exclusion list, and prior authorization pathway for HCPCS code J0174 (injection, lecanemab-irmb, 1 mg) on commercial plans. If your practice bills for Alzheimer's disease infusion therapy, this policy controls whether your claims get paid or denied.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Lecanemab-irmb (Leqembi) — CPB 1026 |
| Policy Code | CPB 1026 |
| Change Type | Modified |
| Effective Date | January 29, 2026 |
| Impact Level | High |
| Specialties Affected | Neurology, geriatrics, psychiatry, neuropsychiatry, infusion centers |
| Key Action | Confirm amyloid confirmation method, staging scores, and prescriber specialty before submitting precertification for J0174 |
Aetna Lecanemab-irmb Coverage Criteria and Medical Necessity Requirements 2026
Aetna's lecanemab-irmb coverage policy requires precertification on all commercial plans — no exceptions. Call (866) 752-7021 or fax (888) 267-3277 to submit. You can also pull the Statement of Medical Necessity (SMN) form from Aetna's Specialty Pharmacy Precertification page.
This is not a simple prior authorization. The criteria stack — every requirement must be met, and a single gap means denial.
Age and genetic criteria: The member must be 50 or older. Members under 50 qualify only with a documented genetic mutation in APP (CPT 81406), PSEN1 (CPT 81405), or PSEN2, or other clinical documentation supporting early-onset AD.
Disease staging: Aetna covers Leqembi only for Clinical Stage 3 (cognitive impairment with early functional impact) or Clinical Stage 4 (dementia with mild functional impact) Alzheimer's disease. Stage 5 or higher is not covered. This matters — a member who has progressed too far doesn't qualify, regardless of amyloid status.
Cognitive scoring at baseline: The member must meet at least one of these score thresholds at baseline:
| # | Covered Indication |
|---|---|
| 1 | CDR-Global Score of 0.5 or 1 |
| 2 | MMSE score of 21–30 |
| 3 | MoCA score of 16 or higher |
Document which tool you used and the exact score. Aetna will look for this in the precertification submission.
Amyloid confirmation: The member must have confirmed amyloid pathology via one of two routes:
| # | Covered Indication |
|---|---|
| 1 | A positive amyloid PET scan (billed with A9586 for florbetapir F18, Q9982 for flutemetamol F18, or A9598 for other radiopharmaceuticals; interpreted with CPT 78608) |
| 2 | A positive CSF amyloid profile from lumbar puncture (CPT 62270), which can include CPT 0445U for the electrochemiluminescent immunoassay for Abeta42 and pTau181 |
Both are valid. CSF is increasingly common when PET access is limited, so make sure your ordering clinician documents the method clearly.
Prescriber requirements: Leqembi must be prescribed by — or in consultation with — a geriatrician, neurologist, psychiatrist, or neuropsychiatrist. A primary care physician alone doesn't meet this requirement. If the billing provider is a PCP, get the specialist consultation on record before submitting.
Site of care: Aetna's Site of Care Utilization Management Policy applies to lecanemab-irmb infusions. This affects where you can administer the drug and still get reimbursement. Check Aetna's drug infusion site-of-care policy before scheduling infusions at a particular facility. Billing infusion administration codes (CPT 96365–96368 or 96413–96417) at a non-approved site will create a claim denial.
Continuation: Aetna requires reauthorization. The member must show clinical benefit on reassessment — no progression beyond Stage 4, no disqualifying new findings on MRI, and no new exclusion criteria. Continued coverage requires ongoing MRI monitoring for ARIA (amyloid-related imaging abnormalities).
Aetna Lecanemab-irmb Exclusions and Non-Covered Indications
The exclusion list here is long and specific. Any one of these disqualifies the member entirely.
Diagnosis exclusions: Cognitive impairment from any neurodegenerative cause other than Alzheimer's disease is excluded. This includes frontotemporal lobar degeneration (FTLD) and Lewy body disease — unless the member has positive AD biomarkers (amyloid PET or CSF). Lewy body disease with confirmed AD biomarkers is a borderline case worth reviewing with your compliance officer before submitting.
Imaging-based exclusions: MRI showing more than four cerebral microbleeds, cortical superficial siderosis, or major vascular contributions to cognitive impairment disqualifies the member. Brain aneurysm, vascular malformation, CNS infection, brain tumor, encephalomalacia, or cerebral contusion are also disqualifying. Relevant brain tumor ICD-10 codes (C71.0–C71.9, C70.0, D33.0–D33.2) appear in the policy's exclusion-adjacent code set.
Vascular and neurological history: TIA, stroke, uncontrolled hypertension, or seizures within the past 12 months are absolute exclusions. Bill accordingly — if you see any of these in the member's recent history, the claim will not survive review.
Hematologic exclusions: Active bleeding disorders, platelet count below 50,000, or INR above 1.5 disqualify the member. The heparin codes (J1642, J1643, J1644) and hemorrhagic condition codes (D69.0–D69.9) in this policy exist to document concurrent conditions — not to enable coverage. A member on anticoagulation therapy needs careful hematology review before any precertification submission.
Immunologic exclusions: Members on immunoglobulins, monoclonal antibodies, immunosuppressants, or plasmapheresis don't qualify. Document all concurrent biologics.
Combination therapy: Leqembi cannot be billed or administered alongside any other amyloid beta-directed antibody — including aducanumab or donanemab. If a member has recently transitioned from another anti-amyloid therapy, document the washout period.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| AD, Clinical Stage 3 or 4, age 50+, amyloid confirmed | Covered | J0174, G30.0–G30.9 | Full criteria must be met; precertification required |
| AD, age under 50 with APP/PSEN1/PSEN2 mutation | Covered | J0174, CPT 81406, 81405 | Genetic documentation required |
| Lewy body disease with confirmed AD biomarkers | Review Required | — | Borderline; check with compliance before submitting |
| Frontotemporal lobar degeneration (FTLD) | Not Covered | G31.10–G31.12 | Excluded regardless of amyloid status |
| Lewy body disease without AD biomarkers | Not Covered | — | Explicitly excluded |
| AD Stage 5 or higher | Not Covered | — | Only Stages 3 and 4 qualify |
| Leqembi + aducanumab or donanemab combination | Not Covered | — | Combination with any amyloid beta-directed antibody excluded |
| Member with >4 cerebral microbleeds on MRI | Not Covered | CPT 70551–70553 | MRI exclusion criterion |
| Member with stroke/TIA/seizures in past 12 months | Not Covered | — | 12-month lookback required |
| Member with platelet count <50,000 or INR >1.5 | Not Covered | J1642–J1644 | Hematologic exclusion |
| Amyloid PET confirmation | Covered (diagnostic) | A9586, Q9982, A9598, CPT 78608 | Required to confirm eligibility |
| CSF amyloid confirmation via LP | Covered (diagnostic) | CPT 62270, CPT 0445U | Alternative to PET |
| Genetic testing for early-onset AD under 50 | Covered (diagnostic) | CPT 81405, 81406, 81401 | Only when supporting under-50 eligibility |
Aetna Lecanemab-irmb Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Confirm precertification is in place before infusion. Call (866) 752-7021 or fax the SMN to (888) 267-3277. Leqembi billing without precertification will result in claim denial. Do this before January 29, 2026 for any patients already in the pipeline. |
| 2 | Verify site of care approval. Aetna's Site of Care UM Policy applies to J0174 infusions. Check which sites are approved for specialty drug infusions before scheduling. Infusion administration codes CPT 96365–96368 (standard IV infusion) or CPT 96413–96417 (chemotherapy-style administration) billed at a non-approved site will not get reimbursement. |
| 3 | Pull baseline cognitive scores and document them. CDR-GS, MMSE, or MoCA — pick one and document the exact score. You need the score, the tool, and the date. Missing this from the record is the most common reason these precertification requests come back incomplete. |
| 4 | Confirm amyloid testing method and code it correctly. PET-based confirmation: use A9586 (florbetapir F18), Q9982 (flutemetamol F18), or A9598 with CPT 78608. CSF-based confirmation: use CPT 62270 with CPT 0445U if the ECLIA assay was used. If a member under 50 is qualifying via genetics, use CPT 81405 (PSEN1) or CPT 81406 (APP). Get these on the claim — they support medical necessity and belong in the record. |
| 5 | Verify prescriber specialty before submitting. The prescribing or consulting physician must be a geriatrician, neurologist, psychiatrist, or neuropsychiatrist. If a PCP is managing the case, get a specialist consultation note in the chart. Missing prescriber specialty documentation is a clean denial. |
| 6 | Run the exclusion checklist before every submission. Check MRI results for microbleeds and siderosis (CPT 70551–70553). Check for TIA, stroke, or seizures in the past 12 months. Check platelet count and INR. Check for concurrent amyloid-directed therapies. One hit on this list ends coverage eligibility. |
| 7 | Build a reauthorization calendar now. Continuation requires documented clinical benefit and updated MRI. Know your reauth intervals and assign ownership to a team member. Missing a reauth deadline breaks the coverage chain and creates a gap in lecanemab-irmb billing. |
If you're managing a high volume of Leqembi patients across a neurology or memory care practice, loop in your compliance officer before January 29, 2026. The interaction between anticoagulant exclusions (J1642–J1644), ARIA monitoring requirements, and site-of-care rules creates real exposure if any piece is missed.
| 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 Lecanemab-irmb Under CPB 1026
HCPCS Codes — Covered When Selection Criteria Are Met
| Code | Type | Description |
|---|---|---|
| J0174 | HCPCS | Injection, lecanemab-irmb, 1 mg |
HCPCS Codes — Related (Diagnostic Confirmation and Monitoring)
| Code | Type | Description |
|---|---|---|
| A9586 | HCPCS | Florbetapir F18, diagnostic, per study dose, up to 10 millicuries |
| A9598 | HCPCS | PET radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified |
| Q9982 | HCPCS | Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries |
| S3852 | HCPCS | DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's disease |
HCPCS Codes — Anticoagulant/Exclusion Documentation
| Code | Type | Description |
|---|---|---|
| J1642 | HCPCS | Injection, heparin sodium (Heparin Lock Flush), per 10 units |
| J1643 | HCPCS | Injection, heparin sodium (Pfizer), not therapeutically equivalent to J1644, per 1,000 units |
| J1644 | HCPCS | Injection, heparin sodium, per 1,000 units |
CPT Codes — Infusion Administration
| Code | Type | Description |
|---|---|---|
| 96365 | CPT | Intravenous infusion administration — initial, up to 1 hour |
| 96366 | CPT | Intravenous infusion administration — each additional hour |
| 96367 | CPT | Intravenous infusion administration — additional sequential infusion |
| 96368 | CPT | Intravenous infusion administration — concurrent infusion |
| 96413 | CPT | Chemotherapy administration, intravenous infusion — initial, up to 1 hour |
| 96414 | CPT | Chemotherapy administration — each additional hour |
| 96415 | CPT | Chemotherapy administration — each additional sequential infusion |
| 96416 | CPT | Chemotherapy administration — initiation of prolonged chemotherapy infusion |
| 96417 | CPT | Chemotherapy administration — each additional sequential infusion, different substance |
CPT Codes — Diagnostic and Eligibility Testing
| Code | Type | Description |
|---|---|---|
| 0445U | CPT | B-amyloid (Abeta42) and phospho tau (181P) (pTau181), electrochemiluminescent immunoassay (ECLIA) |
| 62270 | CPT | Spinal puncture, lumbar, diagnostic |
| 70551 | CPT | MRI brain without contrast material |
| 70552 | CPT | MRI brain with contrast material(s) |
| 70553 | CPT | MRI brain without contrast, followed by contrast and further sequences |
| 78608 | CPT | Brain imaging, PET — metabolic evaluation |
| 81401 | CPT | Molecular pathology procedure, Level 2 — APOE common variants |
| 81405 | CPT | Molecular pathology procedure, Level 6 — PSEN1 full gene sequence |
| 81406 | CPT | Molecular pathology procedure, Level 7 — APP full gene sequence |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| G30.0–G30.9 | Alzheimer's disease (multiple specificity codes) |
| G31.1, G31.10–G31.12 | Other degenerative diseases of nervous system (frontotemporal, etc.) |
| G23.0–G23.9 | Other degenerative diseases of basal ganglia |
| C70.0 | Malignant neoplasm of cerebral meninges |
| C71.0–C71.9 | Malignant neoplasm of brain (exclusion codes) |
| C79.31–C79.32 | Secondary malignant neoplasm of brain and cerebral meninges |
| D33.0–D33.2 | Benign neoplasm of brain |
| D43.0–D43.2 | Neoplasm of uncertain behavior of brain |
| D49.6 | Neoplasm of unspecified behavior of brain |
| D69.0–D69.9 | Purpura and other hemorrhagic conditions (exclusion codes) |
The full ICD-10 code set under CPB 1026 includes 234 codes. The table above reflects the primary covered diagnosis codes and key exclusion-related codes from the policy data. Access the complete list at PayerPolicy CPB 1026.
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