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AetnaCommercial · Coverage · Medical Policy · Oncology, HematologyMedium impact

Tisagenlecleucel (Kymriah) (CPB 0920, reviewed 2026-02-24)

Effective date
Not stated in the notice
Identified
Aug 18, 2026

Summary

Aetna Clinical Policy Bulletin 0920 sets the commercial medical coverage criteria for tisagenlecleucel (Kymriah), a CD19-directed autologous CAR T-cell therapy. Aetna considers it medically necessary for relapsed or refractory B-cell precursor acute lymphoblastic leukemia in members under 26 years of age, for specified relapsed or refractory adult B-cell lymphomas (including DLBCL and follicular lymphoma) under stated criteria, for ALK-positive large B-cell lymphoma if CD19-positive, and for histologic (Richter) transformation to DLBCL under stated criteria. Aetna considers all other indications experimental, investigational, or unproven, including adult ALL, AML, CLL, Hodgkin lymphoma, plasma cell disorders, and repeat administration of the therapy.

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What to do

Action · 8 steps
01REQUIREMENTS: Precertification of tisagenlecleucel (Kymriah) is required of all Aetna participating providers and members in applicable plan designs.
02Contact National Medical Excellence (NME) at 1-877-212-8811 for precertification.
03Aetna considers members not eligible for Kymriah if they have previously received the requested medication or another CD19-directed CAR T-cell therapy, have inadequate and unstable kidney, liver, pulmonary, or cardiac function, have active or latent hepatitis B, active hepatitis C, or any active uncontrolled infection, have active graft versus host disease, or have an active inflammatory disorder.
04For pediatric and young adult ALL requests, the member must be under 26 years of age, have CD19 tumor expression in bone marrow or peripheral blood, have at least 5% lymphoblasts in the bone marrow, and have a Karnofsky (age 16 or older) or Lansky (under 16) performance status of 50% or greater, along with the Philadelphia chromosome and disease-status criteria in the policy.
05For adult B-cell lymphoma requests, the member must be 18 or older, have received two or more lines of systemic therapy, not have primary central nervous system lymphoma, and have an ECOG performance status of 0 to 2.
06The policy lists HCPCS Q2042 (tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation, per therapeutic dose) and CPT 38225 through 38228 as covered codes if selection criteria are met, and lists CPT 96365 through 96368 and 96413 through 96417 as related infusion and chemotherapy administration codes.
07Aetna considers repeat administration of tisagenlecleucel experimental and investigational.
08Continuation of therapy is addressed in the policy's Dosage and Administration information.

Codes mentioned

3822538226382273822896365963689641396417Q2042C82.00C82.99C82.9AC83.30C83.3AC83.80C83.8AC91.00C91.02D47.Z1C71.0C71.9C74.00C74.92C81.00C81.99C84.A0C84.A9C84.60C84.79C90.00C90.02C90.20C90.22C91.10C91.12C91.50C91.52C91.60C91.62C92.00C92.02

Original notice

Tisagenlecleucel (Kymriah) (CPB 0920, reviewed 2026-02-24)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOncologyHematologyCode 38225Code 38226Code 38227Code 38228Code 96365Code 96368Code 96413Code 96417Code Q2042Code C82.00Code C82.99Code C82.9ACode C83.30Code C83.3ACode C83.80Code C83.8ACode C91.00Code C91.02Code D47.Z1Code C71.0Code C71.9Code C74.00Code C74.92Code C81.00Code C81.99Code C84.A0Code C84.A9Code C84.60Code C84.79Code C90.00Code C90.02Code C90.20Code C90.22Code C91.10Code C91.12Code C91.50Code C91.52Code C91.60Code C91.62Code C92.00Code C92.02

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