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AetnaCommercial · Prior Auth · Medical Policy · HematologyMedium impact

Exagamglogene Autotemcel (Casgevy) (CPB 1052, reviewed 2025-12-31)

Effective date
Not stated in the notice
Identified
Aug 13, 2026

Summary

Aetna's Clinical Policy Bulletin 1052 covers Casgevy (exagamglogene autotemcel) as a one-time single-dose intravenous infusion for sickle cell disease or transfusion-dependent beta thalassemia when the member meets the listed criteria, and the drug receives dedicated GCIT review for Commercial and Medicare lines of business. Precertification is required for all Aetna participating providers and members in applicable plan designs. The criteria cover members 12 or older with a confirmed genotype, a history of severe vaso-occlusive episodes or transfusion needs, eligibility for stem cell transplant without a matched 10/10 HLA-related donor, and for sickle cell disease, an inadequate response, intolerance or contraindication to hydroxyurea. Aetna considers all other indications experimental, investigational, or unproven.

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What to do

Action · 7 steps
01Before the infusion: Get precertification by contacting National Medical Excellence at 877-212-8811.
02Unless the member's health plan has elected not to require it, Casgevy must be administered at an Aetna Institutes GCIT Network site, and the prescriber must be a hematologist or consult with one.
03Providers: For sickle cell disease, document that the member is 12 or older, has genotype beta-s/beta-s, beta-s/beta-0, or beta-s/beta-plus confirmed by molecular or genetic testing, and has at least 2 severe vaso-occlusive episodes per year during each of the previous two years.
04Document that the member is eligible for hematopoietic stem cell transplant but has no matched (10/10) HLA-related donor, has not had a prior transplant or any other gene therapy, and has an inadequate response, intolerance, or contraindication to hydroxyurea.
05For transfusion-dependent beta thalassemia, document that the member is 12 or older, has a non-beta-0/beta-0 or beta-0/beta-0 genotype confirmed by molecular or genetic testing, has received at least 100 mL/kg or 10 units of packed red blood cells per year during the previous two years, has no matched donor, and has not had a prior transplant or other gene therapy.
06Confirm the member does not have the listed exclusions, including HIV, hepatitis B or C, current or prior malignancy, advanced liver disease, uncontrolled seizures, or renal impairment (creatinine clearance less than 60 mL/min/1.73 m2).
07Billing team: Bill J3392 per treatment when the criteria are met.

Codes mentioned

J3392S0176D56.1D57.00D57.09D57.181370813839636596368

Original notice

Exagamglogene Autotemcel (Casgevy) (CPB 1052, reviewed 2025-12-31)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesHematologyCode J3392Code S0176Code D56.1Code D57.00Code D57.09Code D57.1Code 81370Code 81383Code 96365Code 96368

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