CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

CAR-T Therapy "Notification" (PDF) Opens in a New Tab.

Defines notification/coverage criteria and documentation requirements for multiple FDA-approved autologous CAR-T cellular therapies (listed products) for specified hematologic malignancies, dosing limits, lymphodepletion regimens, and one-course-per-lifetime duration. Includes HCPCS/Q-codes, related CPT and revenue code mapping, and distribution note.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyCAR-T Therapy "Notification" (PDF) Opens in a New Tab.

Policy CodePolicy N/A

Change TypeCoding and criteria updates

Effective DateApr 1, 2026

Next Review Date

Key ActionProvider must submit medical record documentation supporting all indicated criteria for the selected CAR-T product, including diagnosis, prior therapies, planned lymphodepleting regimen, planned dose, and absence of specified CNS disease or prior allogeneic HSCT when required.

SourceLink

POLICY UPDATE CHANGES

Added Gene/Cellular Therapy distribution channel management language according to benefit booklet for clarity.

Added new indication for Breyanzi for relapsed or refractory marginal zone lymphoma (MZL) for adults after at least 2 prior lines of systemic therapy.

Added HCPCS code Q2058 for Aucatzyl (effective 7/1/2025) and removed certain miscellaneous codes.

Added C9301 to dosing reference table effective 4/1/2025; C9399 termed 3/31/2025.

Added newly approved Aucatzyl and updated indications for Breyanzi, Tecartus, and other minor adjustments (January 2025v2).

Added supporting CPT codes 38225-38228 replacing temporary T-codes effective 1/1/2025.

For Abecma and Carvykti, indications and prior-line requirements were expanded per updated FDA labels in April 2024v2.

Multiple product indications were added across 2022-2024 (Carvykti, Tecartus ALL indication, Yescarta expanded indication, Breyanzi additions).

Removed criteria requiring no active infection including hepatitis B, hepatitis C, and HIV (June 2021).

Removed specific weight dosing within Yescarta criteria per updated FDA label, and added requirement of documentation of planned dose (June 2021).

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

8Restricted CAR-T products listed

7HCPCS Q-codes provided

2Revenue codes added Apr 2026

1Treatment course per lifetime

180Duration of approval (days)

Coverage Summary

Overview: This policy addresses coverage for multiple FDA‑approved autologous CAR‑T products including axicabtagene ciloleucel (Yescarta), brexucabtagene autoleucel (Tecartus), ciltacabtagene autoleucel (Carvykti), idecabtagene vicleucel (Abecma), lisocabtagene maraleucel (Breyanzi), obecabtagene autoleucel (Aucatzyl), and tisagenlecleucel (Kymriah) (listed products).

Coverage stance and limits: Coverage is conditional (covered with product‑specific medical necessity criteria). Coverage is limited to one treatment course per lifetime (duration 180 days) and to one unit per therapeutic dose per product as specified in the policy.

Required documentation and expectations: Providers must submit medical record documentation supporting the selected product’s indication, patient age, prior therapies, required disease testing (eg CD19 expression when specified), planned lymphodepleting chemotherapy regimen and timing, and documentation of the planned CAR‑positive viable T cell dose (must not exceed product‑specific maximums).

Dosing and lymphodepletion: Product‑specific dosing ranges and required lymphodepleting chemotherapy regimens are specified by product (examples summarized in thresholds). Planned dosing must adhere to the product maximums and any weight‑based calculations where applicable; lymphodepleting agents and timing must follow the exact regimen required for the product.

Distribution and billing note: For certain CAR/gene cellular therapies distribution from a specialty pharmacy provider and specific revenue code mapping may be required; providers should contact Blue Cross NC to coordinate and use the specified Q20xx HCPCS codes and updated revenue codes (eg 0891, 0892) as applicable.

Medical Necessity Criteria (product-specific)

General - Restricted products and applicability

The restricted product(s) may be considered medically necessary when the following criteria are met:

General applicability: Request is for one of the specified CAR-T products (tisagenlecleucel, axicabtagene ciloleucel, brexucabtagene autoleucel, lisocabtagene maraleucel, idecabtagene vicleucel, ciltacabtagene autoleucel, obecabtagene autoleucel)

Product-specific branches follow

Tisagenlecleucel (Kymriah) — pediatric/young adult B-cell precursor ALL and adult LBCL/FL

Covered when ALL of the following for the selected indication are met:

Pediatric/young adult B-cell precursor ALL (tisagenlecleucel)

Core criteria
- Ph+ ALL: For Ph+ ALL: tried and had inadequate response to at least two TKIs OR intolerance/FDA labeled contraindication/hypersensitivity to ALL TKIs

Coding (HCPCS / CPT / Revenue)

CAR-T HCPCS codes (covered per therapeutic dose)HCPCSCovered

Q2041	Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2042	Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2053	Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2054	Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2055	Idecabtagene vicleucel, up to 460 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2056	Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2058	Obecabtagene autoleucel, up to 400 million CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose

HCPCS codes (CAR-T product descriptors)HCPCSCovered

Q2041	Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2042	Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2053	Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2054	Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2055	Idecabtagene vicleucel, up to 460 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2056	Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Q2058	Obecabtagene autoleucel, up to 400 million CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Related CPT codes (for cell therapy procedures / apheresis / infusion)CPT

38225
38226
38227
38228
0870
0871
0872
0873
0874
0875

Added supporting CPT codes (replacements)CPTCovered

38225	replaces 0537T (effective 1/1/2025) - related to cellular therapy procedures
38226	replaces 0538T (effective 1/1/2025)
38227	replaces 0539T (effective 1/1/2025)
38228	replaces 0540T (effective 1/1/2025)

Revenue code mappingRevenue

0871	Assign to CPT 38225
0872	Assign to CPT 38226
0873	Assign to CPT 38227
0874	Assign to CPT 38228
0891	Other applicable revenue code
0892	Other applicable revenue code

Revenue codes addedRevenueCovered

0891	Special Processed Drugs - FDA Approved Cell Therapy (added April 2026)
0892	Special Processed Drugs - FDA Approved Gene Therapy (added April 2026)

Deleted / terminated HCPCS/CPT/J-codes historically (examples)mixedNot Covered

C9301	deleted 6/30/2025 (was added earlier 4/1/2025)
C9399	termed 3/31/2025 or earlier historical deletions
C9081	deleted 12/31/2021 (for Abecma historical)
C9076	deleted 6/30/2021 (historical)
0537T	deleted 12/31/2024 (replaced by 38225)
0538T	deleted 12/31/2024 (replaced by 38226)
0539T	deleted 12/31/2024 (replaced by 38227)
0540T	deleted 12/31/2024 (replaced by 38228)
J3490	historically deleted as miscellaneous billing for CAR-T
J3590	historically deleted as miscellaneous billing for CAR-T

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Provider Actions & Billing Rules

Prior Authorization

Notification requirement and medical necessity documentation

Providers must submit medical record documentation supporting medical necessity for the selected CAR‑T product, including diagnosis, age, prior therapies, CD19 expression where required, planned lymphodepleting regimen, documentation of planned dose (not to exceed product‑specific maximum), and absence of specified CNS disease or prior allogeneic HSCT when required.

Affected HCPCS codes: Q2041, Q2042, Q2053, Q2054, Q2055, Q2056, Q2058

Documentation Required

Lymphodepleting regimen documentation

Documentation must confirm the planned lymphodepleting chemotherapy regimen and timing relative to planned CAR‑T infusion as specified per product (exact agents and doses required). Examples: fludarabine 30 mg/m2 IV daily x4 and cyclophosphamide 500 mg/m2 IV daily x2 for certain ALL indications; fludarabine 25–30 mg/m2 with cyclophosphamide 250–500 mg/m2 on product‑specific schedules; or bendamustine 90 mg/m2 IV x2 days when cyclophosphamide cannot be used. Administration must be within the specified window prior to infusion (typically within two weeks or specified days before infusion).

Background, Evidence & Definitions

FDA‑approved indications (selected examples): Yescarta (axicabtagene ciloleucel) is indicated for adults with relapsed or refractory large B‑cell lymphoma (including DLBCL NOS, primary mediastinal LBCL, high‑grade B‑cell lymphoma, DLBCL arising from follicular lymphoma) and relapsed or refractory follicular lymphoma after two or more lines of systemic therapy; limitations exclude primary CNS lymphoma.

Tecartus (brexucabtagene autoleucel) is approved for adults with relapsed or refractory mantle cell lymphoma (MCL) and for relapsed or refractory B‑cell precursor acute lymphoblastic leukemia (ALL) in adults; Carvykti (ciltacabtagene autoleucel) and Abecma (idecabtagene vicleucel) are approved for relapsed/refractory multiple myeloma per their labeled prior‑therapy requirements; Breyanzi (lisocabtagene maraleucel), Aucatzyl (obecabtagene autoleucel), and Kymriah (tisagenlecleucel) have product‑specific hematologic malignancy indications as detailed in the policy.

Product‑specific dosing examples and HCPCS: Yescarta dosing is based on CAR‑positive viable T cells with a target 2 x 10^6 cells/kg and a maximum of 2 x 10^8 (HCPCS Q2041). Tecartus dosing differs by indication (eg MCL target 2 x 10^6 cells/kg, max 2 x 10^8; adult ALL max 1 x 10^8), Breyanzi dosing is specified as cell‑count ranges (eg 90–110 x 10^6 for many indications; HCPCS Q2054), Abecma and Carvykti doses and Aucatzyl total/split dosing are specified in the product tables (see HCPCS Q2055, Q2056, Q2058, Q2042).

Lymphodepleting chemotherapy regimens: Each product requires a specified pre‑infusion lymphodepleting regimen and timing (examples: Yescarta — cyclophosphamide 500 mg/m2 + fludarabine 30 mg/m2 on days −5, −4, −3; Kymriah for ALL — fludarabine 30 mg/m2 x4 + cyclophosphamide 500 mg/m2 x2 within two weeks prior to infusion; Breyanzi, Abecma, Carvykti, and others specify cyclophosphamide and fludarabine regimens or alternate bendamustine where indicated).

Conditional coverage criteria summary: Coverage is contingent on meeting all product‑specific medical necessity criteria including documented diagnosis, patient age limits, no prior genetically modified T‑cell therapy where required, required prior lines/classes of therapy, absence of specified CNS disease or prior allogeneic HSCT when applicable, receipt/plan for the specified lymphodepleting regimen, and documentation of the planned CAR‑positive viable T cell dose not to exceed product maximum.

Revision History

2026-04-01Added Gene/Cellular Therapy distribution channel management language according to benefit booklet for clarity.Latest

Added revenue codes 0891 and 0892 associated with HCPCS codes for gene/cell therapy.

2025-12Corresponding criteria and dosing table updates

Added new indication for Breyanzi for relapsed or refractory marginal zone lymphoma (MZL) for adults after at least 2 prior lines of systemic therapy.

2025-07-01

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyCAR-T Therapy "Notification" (PDF) Opens in a New Tab.

Policy CodePolicy N/A

Change TypeCoding and criteria updates

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

Disease course: Treated with two cycles of standard chemotherapy without a complete response OR achieved a complete response and experienced multiple relapses following standard chemotherapy (at least 2 cycles)

Adult LBCL/FL (tisagenlecleucel)

Core criteria
- Lymphodepletion options: Received or will receive fludarabine 25 mg/m2 IV daily x3 days and cyclophosphamide 250 mg/m2 IV daily x3 days starting with first dose of fludarabine, OR bendamustine 90 mg/m2 IV daily x2 days for patients unable to receive cyclophosphamide, within two weeks prior to infusion; OR unable to receive lymphodepleting chemo if WBC ≤ 1 x 10^9/L within one week prior to infusion

Axicabtagene ciloleucel (Yescarta)

Covered when ALL of the following are met for eligible indications:

Axicabtagene ciloleucel (Yescarta): Diagnosis of relapsed or refractory B-cell lymphoma (DLBCL NOS, primary mediastinal LBCL, high-grade B-cell lymphoma, DLBCL arising from follicular lymphoma) or relapsed/refractory follicular lymphoma; patient ≥18 years; no prior genetically modified T cell therapy or prior axicabtagene ciloleucel; previous therapy included an anthracycline and an anti-CD20 antibody; planned lymphodepleting chemo cyclophosphamide 500 mg/m2 IV and fludarabine 30 mg/m2 IV on days -5, -4, -3 before infusion; planned treatment will not exceed 2 x 10^8 CAR-positive viable T cells; target dose 2 x 10^6 CAR-positive viable T cells per kg; patient does not have primary CNS lymphoma

Includes LBCL and FL indications per label

Brexucabtagene autoleucel (Tecartus)

Covered when ALL of the following are met for MCL or B-cell ALL indications:

Mantle cell lymphoma (Brexucabtagene autoleucel): Diagnosis of relapsed or refractory MCL; patient ≥18 years; prior therapies include an anthracycline or bendamustine-containing chemotherapy, anti-CD20 monoclonal antibody, and a BTK inhibitor; disease progression after last regimen or refractory to most recent therapy; no prior allogeneic HSCT; lymphodepleting chemo cyclophosphamide 500 mg/m2 IV and fludarabine 30 mg/m2 IV on days -5, -4, -3 prior to infusion; planned treatment will not exceed 2 x 10^8 CAR-positive viable T cells; no prior genetically modified T cell therapy or brexucabtagene autoleucel; no detectable malignant cells in CSF or brain metastases; no history of CNS lymphoma

MCL-specific prior therapy required

Adult B-cell precursor ALL (Brexucabtagene autoleucel): Diagnosis of relapsed or refractory B-cell precursor ALL; patient ≥18 years; no prior genetically modified T cell therapy or brexucabtagene autoleucel; for Ph+ ALL: tried and had inadequate response to at least two TKIs OR intolerance/FDA labeled contraindication/hypersensitivity to ALL TKIs; lymphodepleting chemo fludarabine 25 mg/m2 IV on days -4, -3, -2 and cyclophosphamide 900 mg/m2 IV on day -2 prior to infusion; planned treatment will not exceed 1 x 10^8 CAR-positive viable T cells; disease course criteria (primary refractory after two cycles without CR OR CR with first relapse ≤12 months OR relapsed/refractory after two or more lines OR relapsed/refractory ≥100 days post-allogeneic HSCT); no history of CNS disorders including CNS-2 with neurologic changes and CNS-3

Includes Ph+ branch and disease-course options

Lisocabtagene maraleucel (Breyanzi)

Covered when ALL of the following for applicable diagnoses are met:

Lisocabtagene maraleucel (Breyanzi) - LBCL/CLL/SLL/MCL/MZL

Prior-therapy options for LBCL/eligibility: Experienced disease progression after two or more lines OR refractory to first-line chemoimmunotherapy OR refractory to first-line chemoimmunotherapy and not eligible for HSCT due to comorbidities or age
MZL alternative: Experienced disease progression after two or more prior lines with previous therapy including anti-CD20 + alkylating agent OR relapsed after HSCT
MCL specific prior therapy: Previous therapy included an alkylating agent (eg bendamustine), anti-CD20 monoclonal antibody, and a BTK inhibitor (eg acalabrutinib, ibrutinib, zanubrutinib, pirtobrutinib)

Idecabtagene vicleucel (Abecma)

Covered when ALL of the following are met for multiple myeloma:

Idecabtagene vicleucel (Abecma): Diagnosis of relapsed or refractory multiple myeloma; patient ≥18 years; no prior genetically modified T cell therapy or prior idecabtagene vicleucel; experienced disease progression following trial of two or more lines of systemic therapy; previous therapy included an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody; received or will receive lymphodepleting regimen cyclophosphamide 300 mg/m2 IV and fludarabine 30 mg/m2 IV daily for 3 days before infusion; planned treatment will not exceed 510 x 10^6 CAR-positive viable T cells; no prior allogeneic HSCT

Abecma dosing and lymphodepletion specified

Ciltacabtagene autoleucel (Carvykti)

Covered when ALL of the following are met for multiple myeloma:

Ciltacabtagene autoleucel (Carvykti): Diagnosis of relapsed or refractory multiple myeloma; patient ≥18 years; no prior genetically modified T cell therapy or prior ciltacabtagene autoleucel; experienced disease progression following at least one prior line of systemic therapy; previous therapy included an immunomodulatory agent and a proteasome inhibitor; patient is refractory to lenalidomide; received or will receive lymphodepleting regimen cyclophosphamide 300 mg/m2 IV and fludarabine 30 mg/m2 IV daily for 3 days before infusion; planned treatment will not exceed 1 x 10^8 CAR-positive viable T cells; no prior allogeneic HSCT

Includes lenalidomide-refractory requirement and dosing

Obecabtagene autoleucel (Aucatzyl)

Covered when ALL of the following are met for adult B-cell precursor ALL:

Obecabtagene autoleucel (Aucatzyl): Diagnosis of relapsed or refractory B-cell precursor ALL; patient ≥18 years; no prior genetically modified T cell therapy or prior obecabtagene autoleucel; for Ph+ ALL: tried and had inadequate response to at least two TKIs OR tried and had inadequate response to at least one second-generation TKI OR intolerance/FDA labeled contraindication/hypersensitivity to ALL TKIs; disease-course criteria (primary refractory after two cycles without CR OR CR with first relapse ≤12 months OR relapsed/refractory after two or more lines OR relapsed/refractory after at least 3 months post-allogeneic HSCT); received or will receive lymphodepleting regimen fludarabine 30 mg/m2 IV daily x4 days and cyclophosphamide 500 mg/m2 IV daily x2 days starting with first dose of fludarabine before infusion; has not received other anti-CD19 therapy OR previously received other anti-CD19 therapy and re-biopsy indicates CD19 positive disease; planned treatment will not exceed 410 x 10^6 CD19 CAR-positive viable T cells delivered as split dose on day 1 and day 10 (±2 days) determined by marrow blast assessment; no history of CNS disorders including CNS-2 with neurologic changes and CNS-3 disease

Includes Ph+ branch, split-dose dosing and CNS exclusions

Fludarabine 30 mg/m2 IV daily x4 + cyclophosphamide 500 mg/m2 IV daily x2 (tisagenlecleucel ALL)
Fludarabine 25 mg/m2 IV daily x3 + cyclophosphamide 250 mg/m2 IV daily x3 (tisagenlecleucel lymphoma regimens)
Cyclophosphamide 500 mg/m2 + fludarabine 30 mg/m2 on days -5, -4, -3 (axicabtagene ciloleucel)
Bendamustine 90 mg/m2 IV daily x2 as alternate when cyclophosphamide not feasible

Documentation Required

Dose documentation

Documentation of the planned CAR‑positive viable T cell dose is required and must demonstrate the planned total or weight‑based dose will not exceed the product‑specific maximum. Where weight‑based dosing applies, show the calculation and patient weight.

Tisagenlecleucel (pediatric ≤50 kg): 0.2 to 5.0 x 10^6 CAR+ cells/kg; if >50 kg: 0.1 to 2.5 x 10^8 total (max 2.5 x 10^8)
Axicabtagene ciloleucel (Yescarta): target 2 x 10^6 CAR+ cells/kg, max 2 x 10^8
Brexucabtagene (Tecartus) ALL: 1 x 10^6 CAR+ cells/kg, max 1 x 10^8; MCL: 2 x 10^6/kg, max 2 x 10^8
Idecabtagene (Abecma): 300 to 510 x 10^6 CAR+ cells (max 510 x 10^6)

Billing Rule

Maximum units per patient

Maximum billing: one unit per therapeutic dose and coverage is limited to one treatment course per lifetime (duration 180 days).

Affected HCPCS codes: Q2041, Q2042, Q2053, Q2054, Q2055, Q2056, Q2058
One treatment course per lifetime (duration of approval = 180 days)

Documentation Required

Prior therapy and contraindication evidence

Providers must document prior lines of systemic therapy and, when applicable, either prior exposure to specific agent classes or evidence of intolerance/contraindication.

Anthracycline chemotherapy agents
Anti‑CD20 antibody therapy (e.g., rituximab)
Bruton tyrosine kinase (BTK) inhibitors
Immunomodulatory agents (eg lenalidomide)
Proteasome inhibitors
Anti‑CD38 monoclonal antibody

Prior Authorization

Distribution channel restriction

Some identified gene and cellular therapies may require distribution from a specialty pharmacy provider; contact Blue Cross NC to coordinate authorization and distribution to ensure coverage.

Billing Rule

Use specified HCPCS codes per product

Use the specified Q20xx HCPCS code for each CAR‑T product when billing per therapeutic dose. Do not use replaced miscellaneous J‑ or historical C‑codes after their termination dates; use the current Q‑codes and the updated CPT replacements for prior T‑codes.

Current product Q‑codes: Q2041, Q2042, Q2053, Q2054, Q2055, Q2056, Q2058
Do not use terminated miscellaneous codes (examples: J3490, J3590, J9999, C9301) after their end dates
Support: CPT 38225–38228 replaced temporary T‑codes effective 1/1/2025

Documentation Required

Planned dose documentation requirement (historical/maintained)

Policy maintains historical requirement to document planned dose (added for Yescarta June 2021); ensure the same thorough planned dose documentation practices are applied for all products and retained in the medical record.

Maintain documentation of planned total or weight‑based dose and calculations
Retain evidence that planned dose does not exceed the product‑specific maximum

Prior Authorization

Policy notification / effective dates for coding changes

Policy notifications and coding changes have set notification and effective dates; providers should align prior authorization requests and billing with these dates (example: policy notification issued 2/1/2026 with policy effective date 4/1/2026).

Notification date example: 2/1/2026
Effective date example: 4/1/2026

Refer to product sections for full, exact dosing ranges, lymphodepletion agents/doses and timing, and indication‑specific prior therapy requirements (policy references FDA package inserts for each product).

Reference source	Citation
FDA package insert (policy references FDA package inserts for dosing and indications)	All information referenced is from FDA package insert unless otherwise noted (see SOURCE)
Key trial citation (example)	Maude SL et al. N Engl J Med. 2018;378(5):439-448.
Product-specific FDA label / HCPCS reference (examples)	Axicabtagene ciloleucel (Q2041); Tisagenlecleucel (Q2042); Brexucabtagene autoleucel (Q2053); Lisocabtagene maraleucel (Q2054); Idecabtagene vicleucel (Q2055); Ciltacabtagene autoleucel (Q2056); Obecabtagene autoleucel (Q2058) — see FDA label references for dosing and HCPCS descriptions

Definitions:

CAR‑positive viable T cells — chimeric antigen receptor‑expressing viable T cells as specified per product dosing (policy and HCPCS descriptions reference cell counts/targets and product maximums).

Lymphodepleting chemotherapy — pre‑infusion chemotherapy regimens (for example fludarabine plus cyclophosphamide, or bendamustine when indicated) required to be administered within the specified timing prior to CAR‑T infusion as noted for each product.

Coding change (Aucatzyl)

Added HCPCS code Q2058 for Aucatzyl (effective 7/1/2025) and removed certain miscellaneous codes (C9301, J3490, J3590, J9999 termed 6/30/2025).

2025-04-01Coding change (Aucatzyl)

Added HCPCS code C9301 to dosing reference table effective 4/1/2025; deleted C9399 termed 3/31/2025.

2025-01 (v2)Added newly approved product and indication updates

Added newly approved Aucatzyl and updated indications for Breyanzi, Tecartus, and other minor adjustments (January 2025v2).

2025-01-01Coding change (CPT replacements)

Added supporting CPT codes 38225-38228 replacing temporary T-codes effective 1/1/2025 (0537T-0540T termed 12/31/2024).

2024-04 (v2)Indication expansions (Abecma, Carvykti)

For Abecma and Carvykti, indications and prior-line requirements were expanded per updated FDA labels in April 2024v2.

2024-04Criteria change

Added new indication for Breyanzi for adult patients with relapsed or refractory chronic lymphocytic leukemia (CLL)/SLL with corresponding dosing updates.

2022-11Criteria update

Added indication for Breyanzi for relapsed/refractory large B-cell lymphoma after one line of therapy with associated dosing.

2022-02 to 2022-07Coding and criteria additions

Added Carvykti to policy (March 2022) and related CPT/revenue codes (Feb–July 2022) and HCPCS additions (Q2056 added 10/1/2022 recorded elsewhere).

2021-06Policy point removed from eligibility criteria

Removed criteria requiring no active infection including hepatitis B, hepatitis C, and HIV (June 2021).

2021-06Documentation requirement modification

Removed specific weight dosing within Yescarta criteria per updated FDA label, and added requirement of documentation of planned dose (June 2021).

2024-10Coding update (Carvykti)

Added HCPCS code Q2056 for Carvykti effective 10/1/2022; deletions of legacy miscellaneous codes noted in history.

Historical (2021–2025)Deleted miscellaneous/temporary codes

Deleted various C-, J-, and temporary T-codes over time (examples: C9076, C9081, C9098, C9399, 0537T-0540T, J3490, J3590, J9999) as replaced by Q-codes and CPT codes.