HCPCS A9543 is officially defined as "Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries." HCPCS A9543 is referenced in 10 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 HCPCS A9543 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
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.
Excellus BlueCross BlueShield policy 7.01.69 considers transarterial radioembolization (TARE) with yttrium-90 microspheres medically necessary for unresectable or medically inoperable hepatocellular carcinoma, as a bridge to transplant for patients who meet liver transplant criteria and are waiting, for intrahepatic cholangiocarcinoma, and for unresectable metastatic hepatic tumors that meet the listed criteria (neuroendocrine tumors, colorectal, breast, and melanoma). A second TARE is considered medically necessary for a new, progressive tumor after a satisfactory response to an initial TARE, and a third TARE is considered not medically necessary. The version effective February 19, 2026 is an annual review with policy intent unchanged, following a 02/20/25 revision that added statements for primary intrahepatic cholangiocarcinoma and for metastatic hepatic tumors related to cutaneous melanoma.
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.
Carelon Medical Benefits Management clinical appropriateness guidelines for genetic testing, radiation therapy, advanced imaging and oncologic imaging were updated for dates of service on and after March 17, April 14 and June 30, 2024. Carelon also began applying its clinical appropriateness guidelines and cancer treatment pathways effective March 7, 2024. Premera HMO medical policies and drug criteria were revised under effective dates of March 1, April 4 and June 7, 2024, and Federal employee plans received new cervical spine, lumbar spine and site of service surgery policies effective March 7, 2024.
Aetna's Clinical Policy Bulletin 0020 on injectable medications was last reviewed March 5, 2026 and is scheduled for its next review January 14, 2027, but the page does not list what changed. It covers injectables when no appropriate oral alternative exists, excludes experimental drugs and performance-enhancing steroids, and notes that contraceptive injectables, infertility injectables and travel immunizations are excluded under some benefit plans.
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