Linvoseltamab-gcpt (Lynozyfic) — CPB 1089 | AETNA Coverage Update

Aetna modified CPB 1089 for linvoseltamab-gcpt (Lynozyfic), effective December 4, 2025. Here's what billing teams need to do.

Aetna updated its linvoseltamab-gcpt (Lynozyfic) coverage policy under CPB 1089 with a December 4, 2025 effective date. This drug is indicated for relapsed or refractory multiple myeloma. (Note: the BCMA/CD3 mechanism of action description is pharmacological background — it's not sourced from CPB 1089.) The policy governs precertification requirements and medical necessity criteria for commercial plans, with administration billed under CPT 96413, 96414, and 96415, and the drug itself not yet assigned a dedicated J-code — a billing wrinkle your team needs to address now.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Linvoseltamab-gcpt (Lynozyfic) — CPB 1089
Policy Code	CPB 1089
Change Type	Modified
Effective Date	December 4, 2025
Impact Level	High
Specialties Affected	Hematology, Oncology, Infusion Centers
Key Action	Confirm prior authorization and document all four prior therapy categories before submitting claims for C90.00 or C90.02

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Aetna Linvoseltamab-gcpt Coverage Criteria and Medical Necessity Requirements 2025

The Aetna linvoseltamab-gcpt coverage policy under CPB 1089 sets a high bar. Aetna considers Lynozyfic medically necessary for relapsed or refractory multiple myeloma only when the patient has received at least four prior therapies. Those therapies must span three specific drug categories — and all three must be documented.

The three required prior therapy categories are:

#	Covered Indication Copy
1	A proteasome inhibitor — bortezomib (J9041, J9046, J9048, J9049, J9051, J9054), ixazomib, or carfilzomib (J9047)
2	An immunomodulatory agent — lenalidomide, pomalidomide, or thalidomide
3	An anti-CD38 monoclonal antibody — daratumumab (J9144, J9145) or isatuximab (J9227)

All three categories must be represented in the treatment history. Four prior lines total, at minimum. Miss one category and the claim fails medical necessity review.

This is a triple-class exposed (TCE) definition, which aligns with FDA labeling for Lynozyfic. That alignment is helpful — it means you can use the same prior authorization documentation package you'd build for other late-line myeloma agents like teclistamab or elranatamab. If your practice already treats heavily pretreated myeloma patients, this framework is familiar.

Prior authorization is mandatory. Precertification of linvoseltamab-gcpt is required for all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277. Statement of Medical Necessity forms are available through Aetna's Specialty Pharmacy Precertification portal.

Do not administer this drug without confirmed prior auth. The reimbursement risk on a drug at this price point is too high to leave to retroactive appeals.

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Aetna Linvoseltamab-gcpt Continuation of Therapy Criteria 2025

Continuation approval is more straightforward than initial approval, but it's not automatic. Aetna considers continuation therapy medically necessary when the member is requesting reauthorization for multiple myeloma and shows no evidence of unacceptable toxicity or disease progression on the current regimen.

Two conditions, both must be true: no unacceptable toxicity, and no disease progression. Your reauthorization documentation needs to address both points directly. A progress note that says "patient is tolerating therapy well and responding" is not the same as documentation that explicitly states no evidence of progression on current imaging or labs.

Build a reauthorization template that captures both criteria by name. Reviewers are checking for those specific terms.

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Aetna Linvoseltamab-gcpt Exclusions and Non-Covered Indications

Aetna considers all indications for linvoseltamab-gcpt other than relapsed or refractory multiple myeloma — as defined in the initial approval criteria — experimental, investigational, or unproven.

This means any off-label use gets denied. That includes earlier lines of therapy in multiple myeloma (fewer than four prior lines), other plasma cell dyscrasias, or any hematologic malignancy outside the specific C90.00/C90.02 ICD-10 coding. If a physician wants to use Lynozyfic in a patient with three prior lines, that's a denial waiting to happen under this coverage policy.

This policy does not appear to address scenarios where a patient could not tolerate or access a required prior therapy class. If you're facing that scenario, consult your compliance officer before submission — and consider a peer-to-peer before the claim goes in.

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Coverage Indications at a Glance

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Aetna Linvoseltamab-gcpt Billing Guidelines and Action Items 2025

These are the steps your billing team needs to take before — and after — the December 4, 2025 effective date.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Linvoseltamab-gcpt (Lynozyfic) Under CPB 1089

Covered CPT Codes — Infusion Administration

Code	Type	Description Copy
96413	CPT	Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug
96414	CPT	Chemotherapy administration, intravenous infusion technique; each additional sequential infusion of a new substance/drug, up to 1 hour
96415	CPT	Chemotherapy administration, intravenous infusion technique; each additional hour

HCPCS Codes — Prior Therapy Documentation Reference

These codes represent the drug classes required as prior therapy to establish medical necessity. They appear in CPB 1089 and are relevant to prior auth documentation and prior claims verification.

Key ICD-10-CM Diagnosis Codes

Code	Description Copy
C90.00	Multiple myeloma not having achieved remission
C90.02	Multiple myeloma in relapse

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