C14.0 Insurance Policy Changes

ICD-10 C14.0 is officially defined as "Malignant neoplasm of pharynx, unspecified." code C14.0 is referenced in 11 tracked payer policy changes from Independence Blue Cross and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C14.0 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Independence Blue Cross · Effective Aug 25, 2025High impact
08.02.23, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross published a new medical policy (08.02.23b) establishing coverage criteria for tislelizumab-jsgr (Tevimbra®), a PD-1 monoclonal antibody immunotherapy. The policy covers multiple cancer indications with specific medical necessity criteria, including anal carcinoma, appendiceal neoplasms, chronic lymphocytic leukemia, colon cancer, endometrial carcinoma, esophageal cancers, gastric cancer, head and neck cancers, hepatocellular carcinoma, Hodgkin lymphoma, rectal cancer, and small bowel adenocarcinoma. Billing teams must implement this policy effective August 25, 2025, ensuring claims are only processed when documented medical necessity criteria are met.
Independence Blue Cross · Effective Oct 1, 2026Medium impact
MA08.173b, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross Medicare Advantage added ICD-10 code C78.32 (Secondary malignant neoplasm of pharynx) to policy MA08.173b for tislelizumab-jsgr (Tevimbra®) coverage effective 10/01/2026. This expands the conditions for which this immunotherapy drug is covered under Medicare Advantage plans.
Independence Blue Cross · Effective Oct 1, 2026Medium impact
08.02.23b, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross updated policy 08.02.23b for Tislelizumab-jsgr (Tevimbra®) to add ICD-10 code C78.32 (Secondary malignant neoplasm of pharynx) effective October 1, 2026. This is a coding update that expands the diagnosis codes for which this immunotherapy drug is covered under the policy's existing medical necessity criteria.
Independence Blue Cross · Effective Jun 1, 2026Medium impact
MA08.186a, Penpulimab-kcqx
Independence Blue Cross Medicare Advantage policy MA08.186b expands coverage for penpulimab-kcqx to include three new cancer indications (anal carcinoma, appendiceal cancers, and small bowel adenocarcinoma) effective June 1, 2026, and revises head and neck cancer criteria per FDA and NCCN guidelines. Billing teams must add 13 new ICD-10 diagnosis codes and update prior authorization and coverage criteria in billing systems.
Independence Blue Cross · Effective Dec 29, 2025Medium impact
MA08.186, Penpulimab-kcqx
Independence Blue Cross published MA08.186b effective 12/29/2025, establishing new coverage criteria for penpulimab-kcqx (an immunotherapy drug) across multiple cancer types including anal carcinoma, appendiceal cancers, and nasopharyngeal carcinoma. This is a new pharmacy policy requiring billing teams to verify medical necessity criteria are met before processing claims, using unclassified drug codes C9399 or J3590.
Independence Blue Cross · Effective Dec 29, 2025Medium impact
08.02.42, Penpulimab-kcqx
Independence Blue Cross published version 08.02.42b of their Penpulimab-kcqx coverage policy, effective 12/29/2025, establishing medical necessity criteria for this immunotherapy drug across anal carcinoma, appendiceal cancers, and head and neck cancers (nasopharyngeal carcinoma). The policy specifies coverage conditions including required genetic markers, prior treatment history, disease stage, and performance status thresholds. Billing teams must understand these criteria to support prior authorization requests and ensure claims meet coverage requirements.
Independence Blue Cross · Effective Aug 25, 2025Medium impact
MA08.173, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross has published MA08.173b, a new Medicare Advantage policy establishing coverage criteria for tislelizumab-jsgr (Tevimbra®), a PD-1 checkpoint inhibitor immunotherapy. The policy covers the drug for multiple cancer types (anal, appendiceal, CLL/SLL, colon, endometrial, esophageal, gastric, head and neck, nasopharyngeal, hepatocellular, Hodgkin lymphoma, rectal, and small bowel adenocarcinoma) as monotherapy or in combination regimens, subject to specific medical necessity criteria including genetic/mutational status, prior treatment history, and performance scores. Billing teams must implement this coverage policy effective 08/25/2025.
Aetna · Identified Oct 8, 2026Medium impact
Docetaxel (CPB 0956, reviewed 2026-10-05)
For commercial medical plans, docetaxel (Beizray, Docivyx, Taxotere, or generic docetaxel) is considered medically necessary for the listed cancer indications, including breast cancer, non-small cell lung cancer, prostate cancer, gastric cancer, head and neck cancer, ovarian cancer, small cell lung cancer, and soft tissue sarcoma. Breast cancer requires the disease-status criteria stated in the policy, and continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen. All other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)
For commercial medical plan members, Aetna considers dostarlimab-gxly (Jemperli) medically necessary under its initial approval criteria for several mismatch repair deficient or microsatellite instability-high cancers, including endometrial, ampullary, breast, colorectal, esophageal, gastric, ovarian, pancreatic, small bowel and anal cancers. It also considers Jemperli in combination with pemetrexed and platinum chemotherapy for first-line metastatic nonsquamous non-small cell lung cancer without genomic aberrations. Members are not eligible when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy, and all other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)
Aetna considers durvalumab (Imfinzi) medically necessary for commercial medical plans when the criteria for a listed indication are met, and considers all other indications experimental, investigational, or unproven. Precertification is required of all Aetna participating providers and members in applicable plan designs, and Aetna considers members not eligible for Imfinzi when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy. Continuation of therapy is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen, up to 12 months total for unresectable stage II or III NSCLC and up to 24 months total for limited stage SCLC.
Independence Blue Cross · Effective Oct 1, 2026Low impact
08.02.42b, Penpulimab-kcqx
Independence Blue Cross updated policy 08.02.42b for Penpulimab-kcqx effective 10/01/2026, adding ICD-10 code C78.32 (secondary malignant neoplasm of pharynx) to the covered diagnosis codes. This is a coding update that expands the policy's diagnostic scope for this immunotherapy drug used in various cancer treatments.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C14.0?

There are 11 tracked policy changes affecting code C14.0, including updates from Independence Blue Cross, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C14.0?

Payers that have issued tracked updates for code C14.0 include: Independence Blue Cross, Aetna.

How do I get notified when code C14.0 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C14.0. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code C14.0?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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08.02.23, Tislelizumab-jsgr (Tevimbra®)

MA08.173b, Tislelizumab-jsgr (Tevimbra®)

08.02.23b, Tislelizumab-jsgr (Tevimbra®)

MA08.186a, Penpulimab-kcqx

MA08.186, Penpulimab-kcqx

08.02.42, Penpulimab-kcqx

MA08.173, Tislelizumab-jsgr (Tevimbra®)

Docetaxel (CPB 0956, reviewed 2026-10-05)

Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)

Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)

08.02.42b, Penpulimab-kcqx

What insurance policy changes affect code C14.0?

Which payers have updated policy for code C14.0?

How do I get notified when code C14.0 policy changes?

Why do payers change policies for code C14.0?