Aetna modified CPB 0924 for axicabtagene ciloleucel (Yescarta), effective February 14, 2026. Here's what billing teams need to do.
Aetna, a CVS Health company, updated its Yescarta coverage policy under CPB 0924 Aetna's Clinical Policy Bulletin governing this CAR-T therapy. The update refines medical necessity criteria across multiple B-cell lymphoma subtypes, adds pediatric indications, and expands covered diagnoses. The primary billing code is HCPCS Q2041, supported by CPT codes 38225–38228 for the CAR-T cell process and 96413–96417 for chemotherapy administration. If your revenue cycle team handles oncology or cellular therapy claims, this change deserves attention before you submit your next Yescarta claim.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Axicabtagene Ciloleucel (Yescarta) — CPB 0924 |
| Policy Code | CPB 0924 |
| Change Type | Modified |
| Effective Date | February 14, 2026 |
| Impact Level | High |
| Specialties Affected | Hematology/Oncology, Bone Marrow Transplant, Cellular Therapy Programs, Hospital Revenue Cycle |
| Key Action | Verify that all Yescarta prior authorization requests route through National Medical Excellence (NME) at 1-877-212-8811 and that diagnosis codes on claims match the updated covered indications |
Aetna Yescarta Coverage Criteria and Medical Necessity Requirements 2026
The Aetna Yescarta coverage policy under CPB 0924 classifies axicabtagene ciloleucel as a Gene-based, Cellular & Other Innovative Therapies (GCIT®) product. That designation triggers dedicated GCIT team review for both commercial and Medicare lines of business. This is not a standard utilization management review — it goes to a specialized team. Make sure your prior authorization requests go to National Medical Excellence (NME) at 1-877-212-8811, not through your standard precertification channel.
Precertification is required for all Aetna participating providers and members in applicable plan designs. Missing this step means your Q2041 claim — which can run into six figures — lands with no authorization. That's a claim denial you won't recover from quickly.
Adult Large B-Cell Lymphomas
Aetna considers Yescarta medically necessary as a one-dose treatment for members 18 and older in two distinct pathways.
Pathway 1 — Two or more prior lines of systemic therapy. The member must have received at least two prior lines and have one of these diagnoses:
| # | Covered Indication |
|---|---|
| 1 | Diffuse large B-cell lymphoma (DLBCL) |
| 2 | DLBCL arising from follicular lymphoma |
| 3 | Histologic transformation of indolent lymphomas to DLBCL |
| 4 | Primary mediastinal large B-cell lymphoma |
| 5 | High-grade B-cell lymphomas (including double/triple hit lymphoma with MYC and BCL2 and/or BCL6 translocations) |
| 6 | HIV-related B-cell lymphomas (including HIV-related DLBCL, primary effusion lymphoma, HHV8-positive DLBCL, and plasmablastic lymphoma — reported with B20 and B10.89) |
| 7 | Monomorphic post-transplant lymphoproliferative disorder (B-cell type) |
| 8 | Follicular lymphoma |
| 9 | Extranodal marginal zone lymphoma of the stomach (gastric MALT) |
| 10 | Extranodal marginal zone lymphoma of nongastric sites (nongastric MALT) |
| 11 | Nodal marginal zone lymphoma |
| 12 | Splenic marginal zone lymphoma |
Pathway 2 — First-line chemoimmunotherapy with relapsed or refractory disease. This is the earlier-line indication. The member only needs one prior line of therapy but must have relapsed or refractory disease with one of these subtypes:
| # | Covered Indication |
|---|---|
| 1 | DLBCL |
| 2 | Primary mediastinal large B-cell lymphoma |
| 3 | High-grade B-cell lymphomas (double/triple hit) |
| 4 | HIV-related B-cell lymphomas |
| 5 | Monomorphic post-transplant lymphoproliferative disorder (B-cell type) |
The real issue here is code specificity. With 897 ICD-10-CM codes in scope, your coders must match the exact lymphoma subtype to the pathway criteria. A generic DLBCL code on a member who only had one prior line of therapy needs the relapsed/refractory designation clearly documented to survive GCIT review.
Pediatric Indications
The policy includes a pediatric indication for primary mediastinal large B-cell lymphoma. The summary data was truncated at this point, so confirm the full pediatric criteria directly at the CPB 0924 source or with your Aetna GCIT contact before submitting a pediatric case. Don't assume adult criteria apply to pediatric members.
Aetna Yescarta Exclusions and Non-Covered Indications
Aetna will not approve Yescarta when any of the following are present. These are hard stops — not factors to weigh against other criteria.
| Exclusion | Clinical Detail |
|---|---|
| Primary CNS lymphoma | Not covered regardless of prior therapy lines |
| Prior CD19-directed CAR-T therapy | Includes Yescarta and any other CD19-directed CAR-T — no repeat treatment |
| ECOG performance status ≥ 3 | Member must have ECOG 0, 1, or 2 at time of request |
| Inadequate organ function | Kidney, liver, pulmonary, or cardiac function must be stable and adequate |
| Active hepatitis B or C | Active infection is disqualifying; controlled/resolved may differ — document clearly |
| Active systemic infection | Any clinically significant active infection is disqualifying |
| Active inflammatory disorder | Active status is disqualifying |
The prior CD19-directed CAR-T exclusion is worth flagging for your clinical team. A member who received tisagenlecleucel (Kymriah) — another CD19-directed CAR-T — is not eligible for Yescarta under this policy. Confirm the member's complete CAR-T history before requesting precertification.
The ECOG ≥ 3 cutoff is also a common denial trigger. Get documented ECOG status in the medical record before submitting. If the physician notes don't explicitly state ECOG, the GCIT reviewer will ask — and that delays authorization on a therapy where timing matters.
Coverage Indications at a Glance
| Indication | Status | Key Codes | Notes |
|---|---|---|---|
| DLBCL — 2+ prior lines | Covered | Q2041, B-cell lymphoma ICD-10 | ECOG 0-2 required |
| DLBCL — relapsed/refractory after 1st-line chemoimmunotherapy | Covered | Q2041 | Must document relapsed/refractory status |
| Primary mediastinal large B-cell lymphoma — 2+ prior lines | Covered | Q2041 | Adult indication |
| Primary mediastinal large B-cell lymphoma — relapsed/refractory after 1st line | Covered | Q2041 | Adult and pediatric (verify pediatric criteria) |
| High-grade B-cell lymphoma (double/triple hit) | Covered | Q2041 | Both pathways eligible |
| HIV-related B-cell lymphomas (incl. HHV8-positive DLBCL) | Covered | Q2041, B20, B10.89 | Extensive subtype list — code precisely |
| Follicular lymphoma — 2+ prior lines | Covered | Q2041 | Not covered under first-line relapse pathway |
| Gastric and nongastric MALT — 2+ prior lines | Covered | Q2041 | Only under 2+ prior lines pathway |
| Nodal and splenic marginal zone lymphoma — 2+ prior lines | Covered | Q2041 | Only under 2+ prior lines pathway |
| Monomorphic post-transplant lymphoproliferative disorder (B-cell) | Covered | Q2041 | Both pathways eligible |
| Primary CNS lymphoma | Not Covered | — | Hard exclusion |
| Prior CD19-directed CAR-T (any) | Not Covered | — | Repeat treatment excluded |
| ECOG ≥ 3 | Not Covered | — | Hard exclusion regardless of diagnosis |
| Active hepatitis B, hepatitis C, or systemic infection | Not Covered | — | Active status disqualifying; document resolution if applicable |
| Active inflammatory disorder | Not Covered | — | Hard exclusion |
Aetna Yescarta Billing Guidelines and Action Items 2026
Axicabtagene ciloleucel billing is among the most complex in oncology. A single missed step — wrong channel for prior auth, missing ECOG documentation, mismatched ICD-10 — can result in a claim denial that takes months to appeal. Here's what to do now.
| # | Action Item |
|---|---|
| 1 | Route all prior authorization requests through NME at 1-877-212-8811. Standard precertification lines won't handle GCIT products. Update your team's contact list and workflow documentation to reflect this channel specifically for Q2041 claims. Do this before your next Yescarta case — not after the denial. |
| 2 | Confirm ECOG performance status is documented in the medical record. ECOG ≥ 3 is an automatic denial. If your physician notes say "poor performance status" without a numeric score, request an addendum. The GCIT team will look for a specific number. |
| 3 | Map each member's diagnosis to the correct pathway before submitting. Two or more prior lines gets a broader list of covered subtypes. First-line relapse/refractory gets a narrower list. Don't assume a covered diagnosis under one pathway is covered under the other. |
| 4 | Audit your ICD-10-CM code selection against the 897 covered codes. The code list is extensive and includes infectious diagnoses (A00.0–B99.9 range for active infections, which appear as exclusions). A code that falls in an exclusion range — like an active systemic infection — can trigger denial even if the lymphoma code is correct. Review both the lymphoma diagnosis code and any comorbidity codes on the claim. |
| 5 | Check prior CAR-T therapy history for every member. Any previous CD19-directed CAR-T — Yescarta, Kymriah, or any other — disqualifies the member. Pull the member's oncology history before submitting. This is a hard stop in the policy, and appeals on this exclusion rarely succeed. |
| 6 | Verify organ function documentation supports the "adequate and stable" standard. Inadequate or unstable kidney, liver, pulmonary, or cardiac function is an exclusion. Your clinical team should document that organ function meets criteria — not just that it was tested. The record should state the function is adequate for CAR-T therapy. |
| 7 | For pediatric primary mediastinal large B-cell lymphoma cases, get the full policy text. The CPB 0924 summary provided here was truncated at the pediatric criteria section. Pull the complete policy from Aetna directly or via the CPB 0924 source before submitting a pediatric case. If you're not sure how the pediatric criteria apply to your case mix, talk to your compliance officer before the effective date. |
| 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 Axicabtagene Ciloleucel (Yescarta) Under CPB 0924
HCPCS Codes — Covered When Selection Criteria Are Met
| Code | Type | Description |
|---|---|---|
| Q2041 | HCPCS | Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR T cells, including leukapheresis |
Q2041 is the primary reimbursement code for the Yescarta product itself. This code appears on your claim alongside the CAR-T process codes below.
CPT Codes — Related to the CAR-T Process
| Code | Type | Description |
|---|---|---|
| 38225 | CPT | CAR-T therapy; harvesting of blood-derived T lymphocytes for development of genetically modified cells |
| 38226 | CPT | Preparation of blood-derived T lymphocytes for transportation (e.g., cryopreservation, storage) |
| 38227 | CPT | Receipt and preparation of CAR-T cells for administration |
| 38228 | CPT | CAR-T cell administration, autologous |
| 96413 | CPT | Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug |
| 96414 | CPT | Chemotherapy administration; each additional hour |
| 96415 | CPT | Chemotherapy administration; each additional sequential infusion |
| 96416 | CPT | Chemotherapy administration; initiation of prolonged chemotherapy infusion (more than 8 hours) |
| 96417 | CPT | Chemotherapy administration; each additional sequential infusion of a new drug/substance |
The 38225–38228 sequence covers the full CAR-T workflow — leukapheresis through administration. The 96413–96417 codes support the lymphodepleting chemotherapy that precedes Yescarta infusion. Make sure your charge capture team maps each step in the process to the right code. Missing a code in this sequence leaves reimbursement on the table.
Key ICD-10-CM Diagnosis Codes
The policy lists 897 ICD-10-CM codes in scope. Below are the clinically and billing-relevant codes most directly tied to the covered indications:
| Code | Description |
|---|---|
| B10.89 | Other human herpesvirus infection — maps to HHV8-positive DLBCL indication |
| B20 | Human immunodeficiency virus (HIV) disease — required for HIV-related B-cell lymphoma indication |
| A00.0–B99.9 | Certain infectious and parasitic diseases (active, uncontrolled) — appears in exclusion context |
The full 897-code list spans malignant neoplasms of nearly every anatomical site. Many of these codes are likely in scope as comorbidity or exclusion markers, not as primary indications. Work with your oncology coders to build a focused mapping of the lymphoma-specific ICD-10 codes that align with the covered indications listed under CPB 0924. The full code list is available at app.payerpolicy.org/p/aetna/0924.
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