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

IMMEDIATELY: (1) Billing team must establish mandatory precertification workflow for all Casgevy cases by contacting Aetna NME at 877-212-8811 BEFORE any treatment authorization or billing. (2) Update billing system to require prior authorization flag for HCPCS code J3392 on all Aetna commercial plans; claims submitted without precertification will be denied. (3) Verify all Casgevy administration occurs at Aetna Institutes GCIT Designated Network facilities—claims from non-network sites will be denied. (4) Providers must confirm patient eligibility against strict criteria: age 12+, confirmed genotype via genetic testing, documented severe VOCs (sickle cell) or transfusion history (thalassemia), HSCT eligibility with no matched 10/10 HLA donor, no prior HSCT or gene therapy, failed/contraindicated hydroxyurea, and absence of all listed exclusion conditions (HIV, HBV, HCV, malignancy, active infection, advanced liver disease, bleeding disorder, immunodeficiency, cerebral vasculopathy, pulmonary hypertension, cardiac/pulmonary dysfunction, uncontrolled seizures, renal impairment <60 mL/min/1.73m²). (5) Front desk staff must flag Casgevy cases for hematologist review at intake; billing team escalates to precertification specialist. (6) Update encounter templates to require documentation of hydroxyurea trial outcome and HLA donor search status. Failure to obtain precertification will result in claim denials; claims without precertification authorization will be rejected.