CurrentAnthemPolicy N/A

Prior authorization requirements for CAR-T Therapy

This document governs Anthem Blue Cross and Blue Shield's requirement that prior authorization (PA) is required for CAR-T (chimeric antigen receptor T-cell) immunotherapy for members; it affects contracted and non-contracted providers submitting claims for CAR-T therapy.

Policy Summary

PayerAnthem

PolicyPrior authorization requirements for CAR-T Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for any CAR-T therapy, including inpatient stays, before delivering or billing for treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA requiredPrior authorization required for CAR-T therapy

Q2040HCPCS code for Tisagenlecleucel (Kymriah)

Q2041HCPCS code for Axicabtagene Ciloleucel

PA for inpatientInpatient stays also require prior authorization

Provider resourcesPA details available via Availity or Provider Services

Coverage and Authorization Requirements

Prior authorization and coverage notes

Coverage requires prior authorization; check contract language and CMS guidelines first. Non-compliance may result in denied claims.

Prior authorization is required for any CAR-T therapy regardless of place of service or billing code.

Prior authorization is required for all inpatient stays involving CAR-T therapy.

Providers should access detailed PA requirements via Availity (Provider Self-Service Tool) or contact Provider Services if unable to access Availity.

State contract language and Centers for Medicare & Medicaid Services (CMS) guidelines, including definitions and specific contract provisions or exclusions, take precedence over these PA rules and must be considered first when determining coverage.

Policy Summary

PayerAnthem

PolicyPrior authorization requirements for CAR-T Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for any CAR-T therapy, including inpatient stays, before delivering or billing for treatment.

SourceLink

On This Page

Provider Responsibilities and Prior Authorization Process

Prior Authorization

Prior authorization required for CAR‑T therapy (including inpatient stays and unlisted codes)

Anthem requires prior authorization for all CAR‑T (chimeric antigen receptor T‑cell) therapy treatments. This PA requirement applies regardless of place of service and even if the therapy is billed with an unlisted code; inpatient stays also require prior authorization. Providers should use Availity (Provider Self‑Service Tool) for detailed PA requirements or contact Provider Services if unable to access Availity.

PA is required for CAR‑T therapy in any form, regardless of place of service or use of an unlisted code.
Inpatient stays involving CAR‑T therapy require prior authorization.
Detailed PA requirements available via the Provider Self‑Service Tool at Availity; providers who cannot access Availity may call Provider Services.

Key Definitions

CAR-T therapy — definition (Chimeric antigen receptor T‑cell immunotherapy)

TermChimeric antigen receptor (CAR) T-cell immunotherapy

DefinitionCAR-T therapy refers to chimeric antigen receptor T‑cell immunotherapy

Coverage requirementPrior authorization is required for CAR‑T therapy regardless of place of service or if billed with an unlisted code

Inpatient staysAll inpatient stays involving CAR‑T therapy require prior authorization

Related HCPCS codesSee codes Q2040 (Tisagenlecleucel) and Q2041 (Axicabtagene Ciloleucel) representing CAR‑T therapy per infusion

OpenPayer

Prior authorization requirements for CAR-T Therapy

Coverage and Authorization Requirements

CAR-T HCPCS Codes

Provider Responsibilities and Prior Authorization Process

Key Definitions

Q2040	Tisagenlecleucel, up to 250 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per infusion (Kymriah)
Q2041	Axicabtagene Ciloleucel, up to 200 million Autologous Anti-CD19 CAR T Cells, including leukapheresis and dose preparation procedures, per infusion