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Policy Criteria Change
Arkansas Blue Cross Blue Shield·AR · Oncology, Hematology·Medical Policy
Effective date
Oct 7, 2026
We identified it
Aug 5, 2026
Summary
This policy updates coverage criteria for Axicabtagene Ciloleucel (Yescarta), a CAR T-cell therapy, to align with current FDA labeling and NCCN guidelines. The policy now covers two FDA-labeled indications (large B-cell lymphoma and follicular lymphoma) plus thirteen off-label indications, with specific eligibility requirements including prior therapy history, organ/bone marrow function assessment, and a lifetime limit of one administration per patient.
Action Required
By October 7, 2026: Billing and prior authorization teams must immediately implement the updated coverage criteria for J3145 (Axicabtagene Ciloleucel) in the authorization and claims processing systems. Update all prior authorization workflows to require documentation of: (1) histologic confirmation of qualifying diagnosis (large B-cell lymphoma, follicular lymphoma, or one of thirteen off-label indications); (2) prior therapy history meeting specific requirements (anti-CD20 monoclonal antibody, anthracycline-containing chemotherapy, and organ/bone marrow function assessment); (3) absence of prior CAR T-cell or genetically modified T-cell therapy; and (4) lifetime administration limit (one per patient maximum). Providers must document medical oncologist/hematologist certification of adequate organ and bone marrow function. Update encounter templates and authorization request forms to capture all required criteria. Update billing software to flag any claims exceeding the one-administration-per-lifetime limit for denial. Train authorization specialists on the new indications (especially off-label categories) and eligibility requirements. Failure to enforce these criteria will result in claim denials for non-compliant submissions.