CPT 79403, in plain terms, covers Therapeutic infusion of a radiolabeled monoclonal antibody through a vein, typically for lymphoma treatment. CPT 79403 is referenced in 9 tracked payer policy changes from Health Net, Independence Blue Cross, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 79403 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 79403 on AAPC
Starting January 1, 2026, Health Net will require prior authorization for new radiation oncology CPT codes 77X05, 77X07, 77X08, and 77X09, while removing prior auth requirements for codes 77750, 79403, A9543, and A9590. Additionally, 17 obsolete radiation oncology codes are being deleted entirely and can no longer be billed.
Independence Blue Cross is updating MA09.020v to MA09.020w effective 01/01/2026, which removes coverage for Zevalin and Azedra radiopharmaceuticals from the eviCore utilization management program, adds four new CPT codes (77436-77439) for radiation therapy planning, removes 21 CPT/HCPCS codes, and revises three existing codes. Billing teams must update systems to reflect these code changes and discontinue billing for removed radiopharmaceutical codes.
Independence Blue Cross updated radiation therapy policy 09.00.56v to 09.00.56w effective 01/01/2026, adding four new CPT codes (77436-77439), removing 23 codes including radiopharmaceuticals and legacy procedure codes, and revising three CPT codes (77402, 77407, 77412). eviCore utilization management guidelines have been updated; refer to their website for current clinical guidelines.
This medical policy sets when radiopharmaceutical cancer treatments are considered medically appropriate: Xofigo for castration-resistant prostate cancer with symptomatic bone metastases, Pluvicto for PSMA-positive metastatic castration-resistant prostate cancer, Lutathera for somatostatin receptor-positive neuroendocrine tumors, strontium-89 chloride for bone pain from confirmed skeletal metastases, and HICON for thyroid carcinoma. Treatment regimens beyond the U.S. Food and Drug Administration approved regimen are considered investigational. The current version is effective September 17, 2026, with an annual review, and the policy intent is unchanged.
Policy 6.01.44 considers radiopharmaceutical treatments for cancer medically appropriate only within their FDA-approved regimen, and requests in excess of that regimen are considered investigational. Xofigo is considered medically appropriate for castration-resistant prostate cancer with symptomatic bone metastases and no known visceral metastatic disease or bulky regional lymph nodes greater than 3 cm on imaging within the past 30 days. Pluvicto, Lutathera, strontium-89 chloride, and HICON (sodium iodide I 131) are each considered medically appropriate only when their listed criteria are met. The September 18, 2025 review added a new Pluvicto indication and removed Azedra and Zevalin because both are no longer commercially available.
Aetna's Clinical Policy Bulletin 0659 covers ibritumomab tiuxetan (Zevalin) for commercial medical plans. Aetna considers it medically necessary for relapsed or refractory, low-grade or follicular B-cell non-Hodgkin lymphoma, and for previously untreated follicular non-Hodgkin lymphoma in members who have achieved a partial or complete response to first-line chemotherapy. Aetna considers all other indications experimental, investigational or unproven, and considers a repeat course of treatment not medically necessary.
Aetna considers ibritumomab tiuxetan (Zevalin) medically necessary for relapsed or refractory, low-grade or follicular B-cell non-Hodgkin's lymphoma (NHL), and for previously untreated follicular NHL in members who have achieved a partial or complete response to first-line chemotherapy. Aetna considers a repeat course of treatment not medically necessary and all other indications experimental, investigational, or unproven. This policy applies to commercial medical plans, and Medicare criteria are in a separate Medicare Part B Criteria document.
This policy was last reviewed 06/24/2024 with no changes. A single course of ibritumomab tiuxetan (Zevalin) may be considered medically necessary for the treatment of relapsed or refractory CD20-positive, low-grade or follicular, B-cell non-Hodgkin lymphoma. Its use for consolidation after chemotherapy in CD20-positive follicular non-Hodgkin lymphoma with a partial or complete response may be considered medically necessary, and its use for initial treatment of follicular lymphoma may be considered medically necessary in patients unable to tolerate standard chemotherapy, such as elderly or frail patients. Consolidation of a first remission after chemotherapy for de novo aggressive B-cell NHL and use as part of a preparatory regimen before autologous or allogeneic hematopoietic cell transplantation are investigational.
Effective September 1, 2023, Premera HMO added a new policy, Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures), 7.01.587, under which a maze or modified maze procedure performed on a non-beating heart during cardiopulmonary bypass is medically necessary, while stand-alone minimally invasive, off-pump maze procedures and hybrid ablation are investigational. Effective September 1, 2023, Zilretta was added for moderate to severe knee osteoarthritis pain in adults, and Xgeva was added effective August 4, 2023 for prevention of skeletal-related events in bone metastases from solid tumors and in multiple myeloma. Effective August 1, 2023, inpatient mental health treatment requires an initial psychiatric evaluation and a medical history and physical examination within one day after admission, and a nursing assessment upon admission followed by nursing staff observation 24 hours per day.
Watch 79403
Get one email when a payer policy names 79403, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.
See every payer rule for 79403
Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 79403 in one place.
Get alerts for changes like this
Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.