Aetna modified CPB 0924 covering axicabtagene ciloleucel (Yescarta) CAR-T therapy, 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, the Clinical Policy Bulletin governing axicabtagene ciloleucel for commercial medical plans. The change affects HCPCS code Q2041 and the full CAR-T therapy code set—CPT codes 0537T through 0540T and 38225 through 38228—along with chemotherapy administration codes 96413–96417. If your team bills for CAR-T infusions, this update is high-stakes. A missed prior authorization or a mismatched indication means a denied claim on a therapy that costs hundreds of thousands of dollars per infusion.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| 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, Infusion Centers, Inpatient Oncology, Cell Therapy Programs |
| Key Action | Confirm prior authorization through Aetna's National Medical Excellence (NME) team before scheduling leukapheresis or infusion for any Yescarta case |
Aetna Yescarta Coverage Policy: Medical Necessity Requirements 2026
The CPB 0924 Aetna coverage policy routes all Yescarta authorization requests through the Aetna GCIT® (Gene-based, Cellular & Other Innovative Therapies) program. This is a dedicated review team—not standard utilization management. That distinction matters. Route your precertification requests to National Medical Excellence (NME) at 1-877-212-8811. Do not submit through standard prior authorization channels.
Yescarta billing is a one-shot authorization. The policy covers axicabtagene ciloleucel as a single-dose treatment. Aetna will not approve retreatment. If a member already received Yescarta or any other CD19-directed CAR-T therapy—including lisocabtagene maraleucel (Breyanzi) or tisagenlecleucel (Kymriah)—they are excluded from coverage entirely under this policy.
Medical necessity under CPB 0924 Aetna splits into two main adult pathways. The first pathway covers members aged 18 and older with B-cell lymphomas who have received two or more prior lines of systemic therapy. The second pathway covers adults with relapsed or refractory DLBCL, primary mediastinal large B-cell lymphoma, high-grade B-cell lymphomas, HIV-related B-cell lymphomas, or monomorphic post-transplant lymphoproliferative disorder (B-cell type) who have received first-line chemoimmunotherapy and failed it.
The second pathway—covering second-line relapsed/refractory disease—is the more aggressive coverage position. Your documentation must show which pathway applies. Vague notes saying "failed prior therapy" will not hold up in a medical necessity review.
CPB 0924 also includes a pediatric indication for primary mediastinal large B-cell lymphoma. The source summary for this update was truncated before the full pediatric criteria were available. Review the complete CPB 0924 policy document for specific pediatric eligibility requirements, including age thresholds and prior therapy requirements, before submitting any pediatric authorization.
Prior authorization is required for all participating Aetna providers and members in applicable plan designs. This applies to the leukapheresis collection codes (CPT 38225 and 0537T), the preparation and transport codes (CPT 38226 and 0538T), receipt and preparation (CPT 38227 and 0539T), and the CAR-T administration itself (CPT 38228 and 0540T), plus Q2041 for the Yescarta product. Every step of the CAR-T billing chain is tied to this precertification.
Aetna Yescarta Exclusions and Non-Covered Indications
Aetna's exclusion list under CPB 0924 is short, but each item is a hard stop. If any one of these applies, Yescarta is not covered—and submitting the claim anyway generates a denial and a billing headache.
Primary CNS lymphoma is excluded. This is an important carve-out because some DLBCL subtypes can have CNS involvement, and the distinction between primary CNS lymphoma and systemic DLBCL with CNS spread matters. Your clinical documentation needs to be explicit about the diagnosis.
ECOG performance status ≥ 3 disqualifies a member. If your documentation shows the patient is largely confined to bed or chair for more than 50% of waking hours, Aetna denies coverage. Make sure the ECOG score in the clinical notes matches the authorization request—discrepancies are a fast path to denial.
Prior CAR-T therapy is an absolute exclusion. This includes any CD19-directed chimeric antigen receptor T-cell therapy, not just a prior course of Yescarta. Document the full treatment history clearly.
Organ function deficits also disqualify members. Inadequate or unstable kidney, liver, pulmonary, or cardiac function triggers the exclusion. Organ function labs need to be current and clearly support eligibility in your prior auth package.
Active infection is the final major exclusion. Active hepatitis B, active hepatitis C, or a clinically significant active systemic infection all disqualify a member. Active inflammatory disorders are also excluded. This is especially relevant for HIV-related B-cell lymphomas—the underlying HIV disease is a covered indication, but the member must not have an active opportunistic infection at the time of treatment.
Coverage Indications at a Glance
| Indication | Status | Key Requirements | Notes |
|---|---|---|---|
| DLBCL (de novo) — adults 18+ | Covered | 2+ prior lines of systemic therapy | Includes DLBCL arising from follicular lymphoma |
| DLBCL (relapsed/refractory after 1st-line chemoimmunotherapy) | Covered | Failed 1st-line chemoimmunotherapy | Second-line pathway; aggressive DLBCL only |
| Primary mediastinal large B-cell lymphoma — adults | Covered | 2+ prior lines OR failed 1st-line chemoimmunotherapy | Both pathways available |
| Primary mediastinal large B-cell lymphoma — pediatric | Covered | See full CPB 0924 policy for pediatric-specific criteria | Full pediatric eligibility criteria not available in this summary; review complete policy before submitting auth |
| High-grade B-cell lymphomas (double/triple hit) | Covered | 2+ prior lines OR failed 1st-line chemoimmunotherapy | MYC + BCL2 and/or BCL6 translocations included |
| HIV-related B-cell lymphomas | Covered | 2+ prior lines OR failed 1st-line chemoimmunotherapy | Includes primary effusion lymphoma, HHV8-positive DLBCL, plasmablastic lymphoma; no active infection allowed |
| Monomorphic post-transplant lymphoproliferative disorder (B-cell type) | Covered | 2+ prior lines OR failed 1st-line chemoimmunotherapy | Both pathways available |
| Follicular lymphoma | Covered | 2+ prior lines of systemic therapy | Second-line pathway not available for FL |
| Gastric MALT (extranodal marginal zone) | Covered | 2+ prior lines of systemic therapy | Second-line pathway not available |
| Nongastric MALT (extranodal marginal zone) | Covered | 2+ prior lines of systemic therapy | Second-line pathway not available |
| Nodal marginal zone lymphoma | Covered | 2+ prior lines of systemic therapy | Second-line pathway not available |
| Splenic marginal zone lymphoma | Covered | 2+ prior lines of systemic therapy | Second-line pathway not available |
| Histologic transformation of indolent lymphoma to DLBCL | Covered | 2+ prior lines of systemic therapy | Transformed FL and other indolent subtypes qualify |
| Primary CNS lymphoma | Not Covered | Absolute exclusion | Hard stop regardless of prior therapy |
| Any member with prior CD19-directed CAR-T therapy | Not Covered | Absolute exclusion | Includes prior Yescarta, Kymriah, Breyanzi, etc. |
| ECOG performance status ≥ 3 | Not Covered | Absolute exclusion | ECOG score must be documented in clinical notes |
| Active hepatitis B or C; active systemic infection | Not Covered | Absolute exclusion | Active inflammatory disorder also excluded |
Aetna Yescarta Billing Guidelines and Action Items 2026
These are specific steps your team needs to take now. The effective date is February 14, 2026—this policy is already active.
| # | Action Item |
|---|---|
| 1 | Route all Yescarta prior authorizations to NME at 1-877-212-8811—not standard prior auth. Aetna's GCIT program handles CAR-T separately. Sending authorization requests through the normal UM queue creates delays and risks a missing-auth denial on a six-figure claim. |
| 2 | Confirm your CDM includes both Category III and permanent CAR-T CPT codes. Aetna's code set under CPB 0924 includes both Category III codes (0537T, 0538T, 0539T, 0540T) and permanent codes (38225, 38226, 38227, 38228). Verify with your facility which set is currently active for claim submission. Submitting a code set your facility isn't credentialed to bill is a common CAR-T billing error. |
| 3 | Document the treatment pathway explicitly before submitting the prior auth. Aetna's two adult pathways have different eligibility criteria. For the second-line relapsed/refractory pathway, you must show the member had first-line chemoimmunotherapy and relapsed or was refractory—not just "failed prior therapy." Vague documentation gets scrutinized and delayed during GCIT review. |
| 4 | Pull current ECOG status and organ function labs into the authorization package. Aetna will deny Yescarta billing if ECOG ≥ 3 or organ function is inadequate. Make sure the clinical notes in your auth package are dated within a clinically reasonable window of the planned treatment date. Stale documentation is a common denial driver. |
| 5 | Verify the member's complete CAR-T treatment history before starting the auth process. Prior CD19-directed CAR-T therapy is an absolute exclusion. This check needs to happen early—before leukapheresis is scheduled—because once collection starts, there's no clean path to coverage if a prior CAR-T history surfaces later. |
| 6 | Use Q2041 for the Yescarta product on the claim. This is the specific HCPCS code Aetna covers for axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR-T cells, including leukapheresis and related processing. Bill Q2041 alongside the appropriate administration code (CPT 38228 or 0540T). Missing Q2041 on the claim or billing it without the authorized auth number is a fast path to a claim denial. |
| 7 | Assign the correct ICD-10-CM diagnosis code to the claim—and match it exactly to the authorized indication. Aetna's covered ICD-10 list under CPB 0924 is extensive, but the diagnosis on the claim must match the indication that was authorized. A mismatched diagnosis code—even a close neighbor in the code set—triggers medical necessity review. |
| 8 | For any pediatric Yescarta case, review the full CPB 0924 policy before submitting auth. The pediatric indication for primary mediastinal large B-cell lymphoma exists under this policy, but the complete eligibility criteria require review of the full policy document. Do not proceed on assumptions about age thresholds or prior therapy requirements for pediatric patients. |
If you're managing CAR-T billing for a high-volume program, loop in your compliance officer before changing any internal workflows around this policy. The financial exposure per case is too high to handle on process assumptions alone.
| 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 Yescarta Under CPB 0924
CAR-T Therapy CPT Codes (Policy-Related)
| Code | Type | Description |
|---|---|---|
| 0537T | CPT | CAR-T therapy; harvesting of blood-derived T lymphocytes for development of genetically modified CAR-T cells |
| 0538T | CPT | Preparation of blood-derived T lymphocytes for transportation (e.g., cryopreservation, storage) |
| 0539T | CPT | Receipt and preparation of CAR-T cells for administration |
| 0540T | CPT | CAR-T cell administration, autologous |
| 38225 | CPT | CAR-T therapy; harvesting of blood-derived T lymphocytes for development of genetically modified CAR-T 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 |
Chemotherapy Administration CPT Codes (Policy-Related)
| Code | Type | Description |
|---|---|---|
| 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, intravenous infusion; each additional sequential infusion |
| 96416 | CPT | Chemotherapy administration, intravenous infusion; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump |
| 96417 | CPT | Chemotherapy administration, intravenous infusion; each additional sequential infusion of a different substance/drug |
HCPCS Code 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 and all related processing |
Key ICD-10-CM Diagnosis Codes
The full ICD-10-CM list under CPB 0924 spans 897 codes. The clinically primary codes for Yescarta billing are below. Your charge capture team should confirm the full covered list through Aetna's policy document or the PayerPolicy code viewer.
| Code | Description |
|---|---|
| B20 | Human immunodeficiency virus [HIV] disease |
| B10.89 | Other human herpesvirus infection [HHV8-positive diffuse large B-cell lymphoma] |
| A00.0–B99.9 | Certain infectious and parasitic diseases [active, uncontrolled — exclusion range] |
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