Exagamglogene Autotemcel (Casgevy) — CPB 1052 | AETNA Coverage Update

Aetna modified CPB 1052 for exagamglogene autotemcel (Casgevy), effective January 5, 2026. Here's what billing teams need to know before submitting claims.

Aetna updated its Casgevy coverage policy under CPB 1052, covering the gene therapy used to treat sickle cell disease and transfusion-dependent beta-thalassemia. The primary billing code is HCPCS J3392 (injection, exagamglogene autotemcel, per treatment), supported by HLA typing CPT codes 81370–81383 and infusion administration codes 96365–96368 and 96413–96417. This is a high-exposure policy update — a single documentation gap will kill your claim.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Exagamglogene Autotemcel (Casgevy)
Policy Code	CPB 1052
Change Type	Modified
Effective Date	January 5, 2026
Impact Level	High
Specialties Affected	Hematology, Bone Marrow Transplant, Gene Therapy Programs
Key Action	Contact Aetna's National Medical Excellence (NME) team at 877-212-8811 for precertification before any Casgevy administration

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Aetna Casgevy Coverage Criteria and Medical Necessity Requirements 2026

Aetna covers one lifetime dose of Casgevy (HCPCS J3392) for two indications: sickle cell disease (ICD-10 D57.x) and transfusion-dependent beta-thalassemia (ICD-10 D56.1). The word "one dose total" is doing a lot of work here. Document everything from the start — there is no second bite at this apple.

Precertification is required. Call Aetna's National Medical Excellence team at 877-212-8811 before treatment. This is not a standard prior authorization through the usual channel — NME handles GCIT products separately. If your team routes this through normal prior auth workflows, expect a denial.

Casgevy is designated as an Aetna Gene-based, Cellular & Other Innovative Therapies (GCIT®) product. That designation means dedicated review by the Aetna GCIT team. It also means the treatment must happen at an Aetna Institutes® GCIT Designated Network facility unless the member's plan has opted out of that requirement. Verify network status before scheduling stem cell collection, not after.

The prescribing physician must be a hematologist or consult with one. Document that consultation in the medical record. If the prescriber is an oncologist or internist acting alone, you have a medical necessity problem before the claim is even built.

Sickle Cell Disease — Medical Necessity Criteria

All of the following must be met for Aetna to consider Casgevy medically necessary for sickle cell disease:

That hydroxyurea step-edit is critical. Aetna requires a documented trial failure or contraindication — not just a preference for gene therapy. Pull hydroxyurea prescription records and adverse event documentation before you submit.

Transfusion-Dependent Beta-Thalassemia — Medical Necessity Criteria

⚠ Verification Required: The source policy summary for beta-thalassemia criteria was truncated in the data available for this post. The criteria below reflect what was available in the source excerpt. Do not rely on this section as a complete or final criteria set. Verify all beta-thalassemia coverage requirements against the full published CPB 1052 policy at aetna.com before submitting any claims or precertification requests for this indication.

For transfusion-dependent beta-thalassemia, the coverage policy requires all of the following (based on available source data — see note above):

The two-year transfusion burden threshold is objective and verifiable — get the transfusion records in hand before you initiate the precertification request. Aetna will ask for them. Check the full policy for any additional criteria not captured here.

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Aetna Casgevy Exclusions and Non-Covered Indications

Aetna will not approve Casgevy if the member has any of the following conditions. These are hard stops — not conditions that can be addressed with additional documentation.

Absolute contraindications under this coverage policy:

Any one of these disqualifies the member. Casgevy billing for a member with an active malignancy or HIV is not a gray area — it will result in a claim denial.

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Coverage Indications at a Glance

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Aetna Casgevy Billing Guidelines and Action Items 2026

Exagamglogene autotemcel billing carries more documentation weight than almost any other therapy you bill. A single missing element — no hydroxyurea trial record, no HLA typing, wrong facility — will cost you a claim denial. Build your workflow around that reality.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Casgevy Under CPB 1052

Covered HCPCS Code (When Selection Criteria Are Met)

Code	Type	Description Copy
J3392	HCPCS	Injection, exagamglogene autotemcel, per treatment

Other Related HCPCS Code

Code	Type	Description Copy
S0176	HCPCS	Hydroxyurea, oral, 500 mg

Key ICD-10-CM Diagnosis Codes

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