J0131 Insurance Policy Changes

Lifileucel (Amtagvi) (CPB 1056, reviewed 2026-04-08)

Aetna has established a new medical policy (CPB 1056) for lifileucel (Amtagvi), a tumor-derived autologous T cell immunotherapy for unresectable or metastatic melanoma. The policy requires precertification for all commercial plans, mandates administration at Aetna Institutes GCIT Network facilities, and specifies strict clinical criteria including prior PD-1 inhibitor and BRAF inhibitor treatment, adequate organ function, ECOG performance status 0-1, and exclusion of uveal/ocular melanoma and uncontrolled brain metastases. Billing teams must implement prior authorization workflows and ensure claims are routed only for eligible patients meeting all specified criteria.