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AetnaCommercial · Prior Auth · Medical Policy · Oncology, HematologyMedium impact

Lisocabtagene Maraleucel (Breyanzi) (CPB 0986, reviewed 2026-09-14)

Effective date
Not stated in the notice
Identified
Oct 3, 2026

Summary

Aetna's Clinical Policy Bulletin 0986 covers one dose of lisocabtagene maraleucel (Breyanzi) for commercial members 18 or older with specified B-cell lymphomas and chronic lymphocytic leukemia or small lymphocytic lymphoma, each under listed prior-treatment criteria, and for relapsed or refractory pediatric primary mediastinal large B-cell lymphoma after at least two chemoimmunotherapy regimens. Members with primary central nervous system lymphoma, a previous CD19-directed CAR T-cell therapy, an ECOG performance status of 3 or higher, or several listed active or unstable conditions are not eligible. Repeat administration and use for solid tumors are considered experimental, investigational, or unproven.

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What to do

Action · 7 steps
01Billing team: Precertification of Breyanzi is required.
02Contact National Medical Excellence at 877-212-8811 before treatment.
03Before billing HCPCS Q2054 (up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation, per therapeutic dose), confirm the member is not excluded, including primary central nervous system lymphoma, a previous CD19-directed CAR T-cell therapy, ECOG status of 3 or higher, active hepatitis B or C, or active graft versus host disease, and confirm the diagnosis and prior therapy history meet the criteria listed for that diagnosis.
04Document the dose in CAR-positive viable T cells: 90 to 110 x 10 to the 6th after one line of therapy for large B-cell lymphoma, 50 to 110 x 10 to the 6th after two or more lines, and 90 to 110 x 10 to the 6th for CLL/SLL, follicular, mantle cell, and marginal zone lymphoma.
05Administration takes place in a certified healthcare facility.
06The policy lists CPT 38225 through 38228 (CAR-T cell harvesting, preparation, receipt and administration) and CPT 96413 through 96417 (chemotherapy administration) as related codes.
07Do not bill repeat administration or treatment of solid tumors as covered, because the policy considers them experimental, investigational, or unproven.

Codes mentioned

382253822638227382289641396417Q2054C82.00C82.99C83.00C83.09C83.0AC83.10C83.19C83.1AC83.30C83.3AC83.80C83.89C84.60C84.69C84.6AC85.20C85.29C91.10C91.11C91.12D47.Z1D68.61D89.810D89.813

Original notice

Lisocabtagene Maraleucel (Breyanzi) (CPB 0986, reviewed 2026-09-14)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOncologyHematologyCode 38225Code 38226Code 38227Code 38228Code 96413Code 96417Code Q2054Code C82.00Code C82.99Code C83.00Code C83.09Code C83.0ACode C83.10Code C83.19Code C83.1ACode C83.30Code C83.3ACode C83.80Code C83.89Code C84.60Code C84.69Code C84.6ACode C85.20Code C85.29Code C91.10Code C91.11Code C91.12Code D47.Z1Code D68.61Code D89.810Code D89.813

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