CommercialPrior AuthHigh impact
Ciltacabtagene Autoleucel (Carvykti) (CPB 1007, reviewed 2026-03-13)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Mar 13, 2026
We identified it
Aug 12, 2026
Summary
Aetna has updated its coverage policy for Carvykti (ciltacabtagene autoleucel), a CAR-T cell therapy for relapsed or refractory multiple myeloma. The policy requires precertification for all commercial plans and establishes specific clinical criteria for approval, including prior treatment requirements, lenalidomide refractoriness, and performance status eligibility. Billing teams must implement mandatory prior authorization workflows and ensure claims are submitted with proper documentation of eligibility criteria.
Action Required
Effective immediately (policy reviewed 2026-03-13): Billing team must implement mandatory precertification workflow for Carvykti (Q2056) claims for all Aetna commercial members. Update billing system to require prior authorization contact with National Medical Excellence (NME) at 877-212-8811 before service delivery. Implement verification checklist in billing software to confirm: (1) member age ≥18 years, (2) prior treatment with immunomodulatory agent AND proteasome inhibitor, (3) lenalidomide-refractory status, (4) no prior CAR-T therapy, (5) ECOG performance status 0-2, (6) adequate kidney/liver/pulmonary/cardiac function, (7) no CNS involvement history, (8) no active infection, (9) no active GVHD, (10) no active inflammatory disorder. Add ICD-10 codes C90.00-C90.02 and C90.10 to covered diagnosis list; deny all other ICD-10 codes (C00.0-C88.91, C90.20-C90.32, C96.0-D09.9) as experimental. Front desk staff must flag all Carvykti referrals for precertification before scheduling. Providers must document all eligibility criteria on treatment authorization forms. Failure to obtain precertification will result in claim denials. Update fee schedules and billing templates by March 13, 2026.