CommercialPrior AuthHigh impact
Axicabtagene Ciloleucel (Yescarta) (CPB 0924, reviewed 2026-10-09)
Aetna·Oncology, Hematology·Medical Policy
We identified it
Oct 15, 2026
Summary
Aetna's Clinical Policy Bulletin 0924 for Axicabtagene Ciloleucel (Yescarta) was reviewed on 2026-10-09 and establishes coverage criteria for this CAR-T cell therapy across multiple B-cell lymphoma indications in adults and pediatric populations. The policy requires precertification for all uses and specifies detailed eligibility criteria, exclusions, and approved diagnoses. This is an existing policy review with no new effective date stated—the billing team should verify current implementation status and confirm applicability to pending and future claims.
Action Required
Verify current implementation of Aetna's Yescarta precertification requirement: Confirm that all providers and billing staff are routing Yescarta cases through National Medical Excellence (NME) at 1-877-212-8811 for precertification before service delivery. Audit recent and pending Yescarta claims to ensure they meet the stated eligibility criteria (prior treatment lines, performance status, organ function, infection/inflammation exclusions). Update billing software and prior authorization workflows to enforce the specific indications listed in the policy (adult B-cell lymphomas with 2+ prior treatment lines, relapsed/refractory disease post-first-line chemoimmunotherapy, Richter transformation, pediatric primary mediastinal large B-cell lymphoma, and primary CNS lymphoma). Flag claims for non-covered indications (ALL, indolent NHL other than specified subtypes, mantle cell lymphoma, solid tumors, repeat administration) as experimental/investigational and route to medical review or denial per plan design. Confirm that CAR-T harvesting, preparation, transportation, and administration codes (CPT 38225–38228) and chemotherapy administration codes (96413–96417) are billed only when Q2041 (Yescarta) is approved and administered.