CommercialPrior AuthHigh impact
Brexucabtagene Autoleucel (Tecartus) (CPB 0980, reviewed 2026-03-13)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Mar 13, 2026
We identified it
Aug 12, 2026
Summary
Aetna updated its clinical policy for Brexucabtagene Autoleucel (Tecartus) effective March 13, 2026, establishing coverage criteria for relapsed/refractory mantle cell lymphoma and B-cell precursor acute lymphoblastic leukemia in adults 18+. All claims require mandatory precertification through National Medical Excellence (NME) at 1-877-212-8811 before treatment. Billing teams must implement precertification workflows and verify patient eligibility against specific disease stage, prior therapy, and organ function exclusions.
Action Required
IMMEDIATE: 1) Billing team must establish precertification requirement in billing system for all Tecartus claims (Q2053) and related CAR-T harvesting/preparation CPT codes (38225-38228). 2) Configure system to route all claims with ICD-10 codes C83.10-C83.19 (mantle cell lymphoma) or C91.00-C91.02 (B-cell precursor ALL) to require prior authorization before claim submission. 3) Update provider communication and encounter templates to mandate NME precertification contact (1-877-212-8811) for all Tecartus cases. 4) Create eligibility checklist in billing workflow requiring verification of: patient age ≥18, disease relapsed/refractory status, no prior CD19-directed CAR-T therapy, ECOG performance status <3, and no active hepatitis B/C, uncontrolled infection, or organ dysfunction. 5) Train front desk and prior auth staff that Tecartus is designated as Aetna GCIT product requiring dedicated review. Consequence: Claims submitted without precertification will be denied; cases not meeting inclusion criteria will be rejected.