CommercialPrior AuthMedium impact
Afamitresgene Autoleucel (Tecelra) (CPB 1068, reviewed 2026-01-14)
Aetna·Oncology·Medical Policy
Effective date
Jan 14, 2026
We identified it
Aug 17, 2026
Summary
Aetna has issued a new medical policy (CPB 1068, effective 2026-01-14) establishing coverage criteria for Tecelra (afamitresgene autoleucel), a gene-based cellular immunotherapy for unresectable or metastatic synovial sarcoma in adults 18+. All Tecelra treatments require precertification through National Medical Excellence (NME) and must be administered at Aetna Institutes® GCIT Designated Centers. Billing teams must implement prior authorization workflows and ensure claims are coded with HCPCS Q2057 only when all stringent HLA typing, MAGE-A4 expression, performance status, and organ function criteria are met.
Action Required
By 2026-01-14: Billing team must implement precertification requirement for all Tecelra (afamitresgene autoleucel) claims. (1) Update billing system to flag CPT/HCPCS codes related to Tecelra (Q2057, 96413, 96415, 80069) with mandatory prior authorization requirement. (2) Direct all providers and members to obtain precertification from National Medical Excellence (NME) at 877-212-8811 before treatment initiation. (3) Verify that Tecelra administration occurs only at Aetna Institutes® GCIT Designated Centers; claims from non-designated centers will be denied. (4) Create pre-claim checklist requiring documentation of: prior chemotherapy treatment, HLA allele positivity (A*02:01P, A*02:02P, A*02:03P, or A*02:06P), MAGE-A4 antigen expression, ECOG performance status 0 or 1, adequate cardiac/renal function, no prior allogeneic stem cell transplant, no active infection/inflammatory disorder, and exclusion of HLA-A*02:05P carriers. (5) Update claim submission templates to require diagnosis codes C49.0-C49.9 (synovial sarcoma only). (6) Train billing staff that Tecelra is a one-time dose therapy; continuation of therapy follows prescribing information guidelines. (7) Communicate to providers that failure to obtain precertification or submit claims from non-designated centers will result in claim denial. (8) Flag for compliance: this is an Aetna GCIT product requiring dedicated review; escalate any questions to NME.