Use specified CPT/HCPCS codes for billing

Use the listed CPT/HCPCS codes for coverage and reimbursement when the policy criteria are met: CPT 38225, 38226, 38227, 38228 and HCPCS Q2041 (Axicabtagene ciloleucel, up to 200 million autologous anti‑CD19 CAR‑positive viable T cells, per therapeutic dose).

• 38225 — harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR‑T cells, per day
• 38226 — preparation of blood‑derived T lymphocytes for transportation (eg, cryopreservation, storage)
• 38227 — receipt and preparation of CAR‑T cells for administration
• 38228 — CAR‑T cell administration, autologous
• Q2041 — Axicabtagene ciloleucel, up to 200 million autologous anti‑CD19 CAR‑positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Prior authorization required

Prior authorization is required for medical benefit coverage of Yescarta; approval is recommended when the patient meets the policy criteria and dosing requirements for the listed B‑cell lymphoma indications.

• Approval duration is 6 months to allow time to prepare and administer one dose

Required prior lines of therapy or relapse timing

Approval depends on specified prior therapies or disease timing: many diagnoses require disease that is relapsed or refractory after two or more lines of systemic therapy, while others allow primary refractory disease or relapse <12 months after first‑line therapy.

• Examples of systemic therapy include R‑CHOP, dose‑adjusted EPOCH + rituximab, RCDOP, DHA + platinum ± rituximab, CHOP + obinutuzumab or rituximab, CVP + rituximab, lenalidomide + rituximab
• Eligibility pathways specify relapsed/refractory after ≥2 lines, primary refractory, or relapse <12 months (depending on diagnosis)

Required clinical documentation for approval

Authorization requires clinical documentation that Yescarta is prescribed by or in consultation with an oncologist and that the patient received or plans to receive lymphodepleting chemotherapy prior to infusion; documentation must also show the patient has not previously received CAR‑T therapy.

• Prescribed by or in consultation with a physician who specializes in the condition being treated (oncologist)
• Document receipt of, or plan to receive, lymphodepleting chemotherapy prior to Yescarta infusion
• Document no prior CAR‑T therapy

Denial triggers — missing codes or prior authorization

Claims submitted without the covered diagnosis or procedure codes listed in the policy or without prior authorization will be denied as not covered.

• Use the covered diagnosis and procedure codes specified in the policy when billing
• Failure to obtain prior authorization for medical benefit coverage will result in denial