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C15.3

PAYER POLICY CHANGES

C15.3 Insurance Policy Changes

ICD-10 C15.3 is officially defined as "Malignant neoplasm of upper third of esophagus." code C15.3 is referenced in 37 tracked payer policy changes from Independence Blue Cross, Health Net, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C15.3 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 Oct 1, 2025High impact
11.03.18, Endoscopic Submucosal Dissection (ESD)
Independence Blue Cross has reissued policy 11.03.18 to establish coverage criteria for Endoscopic Submucosal Dissection (ESD) across four clinical scenarios: esophageal squamous cell carcinoma/dysplasia, early-stage esophageal adenocarcinoma/Barrett esophagus dysplasia, gastric early adenocarcinoma, and colorectal lesions. The policy defines specific lesion characteristics, invasion depth thresholds, and lymph node metastasis documentation requirements that must be met for coverage. Billing teams must now ensure claims include proper documentation of lesion staging and use appropriate HCPCS code C9779 for covered procedures.
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.
Health Net · Identified Jun 20, 2026High impact
21-139 Medical Policies - 4th Quarter 2020
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, wound care, and various diagnostic procedures.
Health Net · Identified Jun 20, 2026High impact
21-141 Medical Policies - 4th Quarter 2020
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, and wound care. Most changes involve revised medical necessity criteria and updated CPT/ICD-10 codes that require immediate attention for proper billing and authorization processes.
Health Net · Identified Jun 20, 2026High impact
21-142 Medical Policies - 4th Quarter 2020
CalViva Health updated multiple medical policies for Q4 2020 affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties. Key changes include revised oxygen therapy criteria, new ambulatory surgery center redirection requirements, updated bariatric surgery protocols, and modified coverage for various diagnostic and therapeutic services.
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.
Excellus BlueCross BlueShield · Effective Feb 19, 2026Medium impact
Photodynamic Therapy for Malignant Disease 8.01.06
Excellus medical policy 8.01.06 covers photodynamic therapy (PDT) for malignant disease. PDT with Photofrin is considered medically appropriate for early-stage non-small-cell lung cancer in patients who are ineligible for surgery and radiation, for completely or partially obstructing endobronchial lesions, for palliative treatment of obstructing esophageal cancer, for Barrett's high-grade dysplasia in patients at high risk during prophylactic esophagectomy who decide on this treatment through shared decision-making, and for palliative treatment of unresectable cholangiocarcinoma as an adjunct to stenting. PDT with 5-aminolevulinic acid is considered medically appropriate for superficial and nodular basal cell skin cancer and for Bowen's disease, only when surgery or radiation is contraindicated, and PDT is considered investigational for other malignancies. The current effective date is February 19, 2026, and the April 28, 2026 edit corrected grammatical errors and alphabetized reference entries.
Independence Blue Cross · Effective Oct 1, 2025Medium impact
MA11.118, Endoscopic Submucosal Dissection (ESD)
Independence Blue Cross has reissued MA11.118 to communicate coverage criteria for Endoscopic Submucosal Dissection (ESD) procedures across four indication categories: esophageal squamous cell carcinoma/dysplasia, early-stage esophageal adenocarcinoma/Barrett esophagus dysplasia, gastric early adenocarcinoma, and colorectal lesions. The policy establishes specific medical necessity criteria for each indication, including lesion size, differentiation, invasion depth, and lymph node metastasis risk documentation. Billing teams must recognize the HCPCS code C9779 for ESD procedures and CPT unlisted codes (43499, 43999, 45399, 45999) as applicable billing options.
Independence Blue Cross · Effective Oct 1, 2025Medium impact
11.03.18, Endoscopic Submucosal Dissection (ESD)
Independence Blue Cross reissued Policy 11.03.18 to communicate coverage criteria for Endoscopic Submucosal Dissection (ESD) across four indications: esophageal squamous cell carcinoma/dysplasia, early-stage esophageal adenocarcinoma/Barrett esophagus dysplasia, gastric early adenocarcinoma, and colorectal lesions. The policy establishes specific clinical criteria (lesion size, differentiation, invasion depth, metastasis risk) that must be met for coverage, and designates all other ESD uses as experimental/investigational and not covered.
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 Nov 7, 2026Medium impact
In Vivo Analysis of Gastro-Intestinal and Urothelial Lesions (CPB 0783, reviewed 2026-10-27)
Aetna's Clinical Policy Bulletin 0783 (reviewed 2026-10-27) confirms that in vivo analysis technologies for gastrointestinal and urothelial lesions, including confocal laser endomicroscopy, narrow-band imaging, chromoendoscopy and optical biopsy systems, are considered experimental, investigational or unproven for the listed indications. Claims for these services with the listed CPT codes (such as 43206, 43252 and +0397T) and ICD-10 diagnoses will be denied under this policy, so billing staff should review how these services are coded and documented before submission.
Aetna · Identified Oct 25, 2026Medium impact
Dysphagia Therapy (CPB 0625, reviewed 2026-10-21)
Aetna's Clinical Policy Bulletin 0625 on dysphagia therapy states which treatments it considers medically necessary and which it considers experimental, investigational, or unproven. Speech therapy for dysphagia, esophageal dilation for symptomatic obstruction of the esophagus, and non-biodegradable, non-drug eluting stent placement for refractory malignant esophageal strictures are medically necessary when the member meets the policy's criteria. Acupuncture, electrical stimulation, transcranial direct current stimulation, hyperbaric oxygen therapy for radiation-induced dysphagia and several other interventions are listed as experimental, investigational, or unproven.
Aetna · Identified Oct 20, 2026Medium impact
Amivantamab-vmjw (Rybrevant) and Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro) (CPB 0995, reviewed 2026-10-16)
Amivantamab-vmjw (Rybrevant) and amivantamab and hyaluronidase-lpuj (Rybrevant Faspro) are considered medically necessary for commercial plans for non-small cell lung cancer when the initial approval criteria are met, and continuation of therapy is medically necessary on reauthorization when there is no evidence of unacceptable toxicity or disease progression. Precertification is required of all Aetna participating providers and members in applicable plan designs. Use for gastro-esophageal cancer and all other indications is considered experimental, investigational, or unproven.
Aetna · Identified Oct 15, 2026Medium impact
Avelumab (Bavencio) (CPB 0916, reviewed 2026-10-14)
Aetna considers avelumab (Bavencio) medically necessary for commercial plan members with Merkel cell carcinoma, renal cell carcinoma in combination with axitinib, urothelial carcinomas, gestational trophoblastic neoplasia, endometrial carcinoma, thymic carcinoma, extranodal NK/T-cell lymphoma, colorectal adenocarcinoma, and small bowel adenocarcinoma when the criteria for each indication are met. Precertification of avelumab is required for all Aetna participating providers and members in applicable plan designs, and members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible. Aetna considers avelumab experimental, investigational, or unproven for all other indications, including breast cancer, non-small cell lung cancer, ovarian cancer, prostate cancer, and pancreatic cancer.
Aetna · Identified Oct 10, 2026Medium impact
Radiofrequency Tumor Ablation (CPB 0492, reviewed 2026-10-05)
Aetna considers radiofrequency ablation (RFA) medically necessary for indications that include colorectal cancer liver metastases, colorectal cancer lung metastases of 5 cm or less where the primary colorectal tumor has been resected for cure (R0 resection), malignant lung masses in persons who are not candidates for surgical intervention, solitary hepatocellular carcinoma of 5 cm or less or multinodular early-stage HCC in members who are ineligible for or decline surgical resection or transplantation, renal cell carcinoma up to 4 cm in high-risk surgical candidates or in persons with renal insufficiency or a solitary kidney, and osteoid osteoma in individuals who remain symptomatic despite NSAIDs. Aetna considers RFA experimental, investigational, or unproven for combined RFA with transarterial chemoembolization for intermediate-stage hepatocellular carcinoma, combined endoluminal RFA and stenting for malignant biliary obstruction or stricture, combined RFA and vertebral cement augmentation for spinal metastases, endoscopic ultrasound-guided RFA for aldosterone-producing adenomas, and all other indications, including curative treatment of primary or metastatic malignant neoplasms in persons able to tolerate surgical resection, biliary obstructions or strictures, renal cysts, renal angiomyolipomas, Brunner's gland hyperplasia, and unresectable localized recurrent thyroid cancers without distant metastases.
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 Oct 3, 2026Medium impact
Liver and Other Neoplasms - Treatment Approaches (CPB 0268, reviewed 2026-09-18)
Aetna considers percutaneous ethanol injection (PEI) medically necessary for hepatocellular carcinoma (HCC) without extra-hepatic spread and for neuroendocrine cancers involving the liver. Chemoembolization is medically necessary for neuroendocrine cancers involving the liver, unresectable primary HCC, liver-only metastasis from uveal melanoma, and pre-operative hepatic artery chemoembolization followed by orthotopic liver transplantation for HCC. Intra-hepatic microspheres (TheraSphere, SIR-Spheres, also known as trans-arterial radio-embolization) are medically necessary for neuroendocrine cancers involving the liver, unresectable primary HCC, unresectable liver tumors from primary colorectal cancer, unresectable and chemo-refractory intra-hepatic cholangiocarcinoma with liver metastases only, and pre-operative use as a bridge to orthotopic liver transplantation for HCC. Intra-hepatic chemotherapy is medically necessary for members with liver metastases from colorectal cancer. Many other uses are listed as experimental, investigational or unproven, including chemoembolization for palliative treatment of liver metastases from non-neuroendocrine primaries, PEI for liver neoplasms when the criteria above are not met, combined electrochemotherapy and immunotherapy for HCC, the TriNav Infusion System, the TheraBionic P1 System, and degradable starch microsphere chemoembolization for HCC.
Aetna · Identified Aug 19, 2026Medium impact
Brachytherapy (CPB 0371, reviewed 2026-05-20)
Aetna considers brachytherapy medically necessary for breast, esophageal, eye tumors, genitourinary cancers other than bladder, gynecologic, head and neck, respiratory and digestive tract, and soft tissue sarcoma indications when the EviCore Healthcare Radiation Therapy Clinical Guidelines criteria are met. It also considers brachytherapy medically necessary for skin cancer where surgical resection and photon or electron beam techniques are contraindicated, and for stenotic obstruction after lung transplantation refractory to other treatments. Brachytherapy for bladder cancer, bone metastases, brain tumors, leukemia, lymphoma, multiple myeloma, pancreatic cancer, keloids, palmoplantar pustulosis, spinal tumors and spinal metastases, and subfoveal choroidal neovascularization secondary to age-related macular degeneration is considered experimental, investigational or unproven, and electronic brachytherapy is considered experimental, investigational or unproven for breast cancer and all other indications.
Aetna · Identified Aug 18, 2026Medium impact
Tremelimumab-actl (Imjudo) (CPB 1019, reviewed 2026-04-27)
Aetna considers tremelimumab-actl (Imjudo) medically necessary for commercial medical plans when it is given with durvalumab (Imfinzi) for hepatocellular carcinoma, non-small cell lung cancer, or esophageal, esophagogastric junction or gastric adenocarcinoma. For hepatocellular carcinoma, a one-time single dose is covered for first-line treatment when the disease is unresectable or extrahepatic/metastatic and the member is ineligible for transplant, or for subsequent treatment when the disease is unresectable or extrahepatic/metastatic and the member has not previously been treated with an anti-CTLA4-based regimen. For non-small cell lung cancer, a total of 5 doses is covered with platinum-based chemotherapy when the tumor is negative for EGFR exon 19 deletion and exon 21 L858R mutations and for ALK, RET and ROS1 rearrangements, and for esophageal, esophagogastric junction or gastric adenocarcinoma, a one-time single dose is covered for neoadjuvant treatment when the tumor is MSI-H or dMMR and the member is medically fit for surgery. Precertification is required of all Aetna participating providers and members in applicable plan designs, and all other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Trastuzumab Products (CPB 0313, reviewed 2026-06-08)
Aetna Clinical Policy Bulletin 0313 sets coverage rules for trastuzumab products for commercial medical plans, including Herceptin and the biosimilars Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant and Trazimera. Aetna considers these products medically necessary for HER2-positive breast cancer in the adjuvant, neoadjuvant and metastatic settings, for HER2-positive esophageal, gastric, biliary, salivary gland, small bowel, appendiceal and uterine serous cancers, and for HER2-positive, RAS and BRAF wild-type colorectal cancer when the listed criteria are met. Aetna considers all other indications experimental, investigational or unproven, including lung, ovarian, pancreatic, prostate, bladder and melanoma, and considers lapatinib plus trastuzumab and pertuzumab plus trastuzumab for HER2-positive breast cancer experimental, investigational or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Tislelizumab-jsgr (Tevimbra) (CPB 1057, reviewed 2025-12-05)
Aetna Clinical Policy Bulletin 1057 sets the commercial medical coverage criteria for tislelizumab-jsgr (Tevimbra). Aetna considers it medically necessary for several cancers under indication-specific criteria, including subsequent treatment of metastatic anal carcinoma, esophageal and esophagogastric junction cancer, HER2-negative gastric adenocarcinoma, metastatic nasopharyngeal cancer, hepatocellular carcinoma, and histologic (Richter) transformation to diffuse large B-cell lymphoma. It also covers MSI-H, dMMR, or POLE/POLD1 ultra-hypermutated small bowel, colon, appendiceal, and rectal adenocarcinomas under the stated criteria, and considers all other indications experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2025-12-03)
Aetna's Clinical Policy Bulletin 0811 considers autologous or allogeneic hematopoietic stem cell transplant, both ablative and non-myeloablative, experimental, investigational, or unproven for the following adult solid tumors: bile duct (cholangiocarcinoma), breast, central nervous system tumors, cervix, colon, esophagus, fallopian tube, gallbladder, kidney, liver, lung, melanoma, nasopharynx, neuroendocrine tumors, pancreas, paranasal sinus, prostate, rectum, soft tissue sarcomas, stomach, thymus, thyroid, tumors of unknown primary origin, and uterus. Aetna considers autologous hematopoietic stem cell transplant medically necessary in young adults with primitive neuroectodermal tumors, medulloblastoma, and Ewing sarcoma family of tumors when criteria are met in CPB 0496.
Aetna · Identified Aug 17, 2026Medium impact
Amivantamab-vmjw (Rybrevant) and Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro) (CPB 0995, reviewed 2026-08-05)
Aetna considers amivantamab-vmjw (Rybrevant) or amivantamab and hyaluronidase-lpuj (Rybrevant Faspro) medically necessary for non-small cell lung cancer (NSCLC) with EGFR exon 19 deletion or exon 21 L858R mutation when used with lazertinib, with carboplatin and pemetrexed after disease progression on osimertinib or lazertinib, or as subsequent treatment as listed in the policy, and for NSCLC with EGFR exon 20 insertion mutation as first-line treatment with carboplatin and pemetrexed for nonsquamous disease or as subsequent single-agent treatment. Aetna considers all other indications, including gastro-esophageal cancer, experimental, investigational, or unproven. Continuation of therapy is considered medically necessary for EGFR-positive NSCLC when there is no evidence of unacceptable toxicity or disease progression on the current regimen. Precertification is required for applicable plan designs.
Aetna · Identified Aug 17, 2026Medium impact
Liver and Other Neoplasms - Treatment Approaches (CPB 0268, reviewed 2026-04-16)
Aetna considers percutaneous ethanol injection, chemoembolization, intra-hepatic chemotherapy and intra-hepatic microspheres (also called TARE) medically necessary for listed liver indications. These include unresectable primary hepatocellular carcinoma (HCC), neuroendocrine tumors involving the liver, liver-only metastasis from uveal melanoma, unresectable liver tumors from colorectal cancer, and pre-operative use before liver transplantation for HCC. The policy considers many other uses experimental, investigational or unproven, including chemoembolization for liver metastases from non-neuroendocrine primaries, combined radiofrequency ablation and percutaneous ethanol injection for HCC, drug-eluting beads for liver metastases from colorectal cancer, the TriNav Infusion System and the TheraBionic P1 System.
Aetna · Identified Aug 15, 2026Medium impact
Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)
Aetna's Clinical Policy Bulletin 0815 covers ipilimumab (Yervoy) for commercial medical plans. It considers ipilimumab medically necessary for the cancer indications listed in the policy, many of them in combination with nivolumab, and considers continued treatment medically necessary for members requesting reauthorization when there is no evidence of unacceptable toxicity or disease progression. It considers ipilimumab experimental, investigational, or unproven for indications such as glioblastoma, pancreatic cancer, and prostate cancer, and for use with bevacizumab, vemurafenib, dabrafenib, or trametinib.
Aetna · Identified Aug 15, 2026Medium impact
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CPB 0966, reviewed 2026-05-15)
Aetna's policy for fam-trastuzumab deruxtecan-nxki (Enhertu) requires precertification from participating providers and members in applicable plan designs, and it covers the drug for commercial medical plans when the criteria for a listed indication are met. Listed indications include HER2-positive breast cancer, HER2-low and HER2-ultralow breast cancer, HER2-positive biliary tract cancer, HER2-positive esophageal, gastric or gastroesophageal junction adenocarcinoma, HER2-mutant non-small cell lung cancer, and HER2-positive (IHC 3+) solid tumors. Several indications are covered only when Enhertu is used as a single agent, and Aetna considers the drug experimental, investigational or unproven for all other indications.
Aetna · Identified Aug 14, 2026Medium impact
Endoscopic Ultrasonography (CPB 0446, reviewed 2026-07-22)
Aetna's Clinical Policy Bulletin 0446 sets coverage rules for endoscopic ultrasonography (EUS). Aetna considers EUS medically necessary for listed indications, including diagnosing common bile duct stones, evaluating abnormalities of the biliary tree and pancreas, staging tumors of the gastrointestinal tract, pancreas and bile ducts, staging lung cancer with fine-needle aspiration, pancreatic cancer screening in individuals with genetic susceptibility, and endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction. EUS is considered experimental, investigational or unproven for all other indications, including diagnosis of esophageal varices, EUS-elastography, evaluation of common bile duct dilation in persons without signs or symptoms, and EUS-guided ablation therapies for pancreatic cystic neoplasms.
Aetna · Identified Aug 13, 2026Medium impact
Photodynamic Therapy (CPB 0375, reviewed 2026-05-21)
Aetna considers photodynamic therapy with porfimer sodium (Photofrin) medically necessary for esophageal cancer, endobronchial non-small cell lung cancer and inoperable cholangiocarcinoma (as an adjunct to stenting) when the listed criteria are met, and experimental, investigational or unproven when they are not. Photodynamic therapy with topical photosensitizers such as methyl aminolevulinate, topical 5-fluorouracil and aminolevulinic acid is medically necessary for basal cell carcinoma, cutaneous lesions of Bowen's disease, refractory actinic keratoses, low-risk squamous cell carcinoma in situ where surgery or radiation is contraindicated or impractical, and erythroplasia of Queyrat. Photodynamic therapy is considered experimental, investigational or unproven for other cancers and for a long list of non-cancer indications, and the policy applies to commercial medical plans.
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.
Aetna · Identified Aug 13, 2026Medium impact
Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)
Aetna considers albumin-bound paclitaxel (Abraxane or generic albumin-bound paclitaxel) medically necessary for the cancers listed in its initial approval criteria, including Kaposi sarcoma, breast cancer, cutaneous melanoma, endometrial carcinoma, ovarian, fallopian tube and primary peritoneal cancer, biliary tract cancers, non-small cell lung cancer, pancreatic adenocarcinoma, small bowel adenocarcinoma, uveal melanoma, ampullary adenocarcinoma, cervical cancer, bladder cancer and vaginal cancer, when each cancer's stated criteria are met. All other indications are considered experimental, investigational, or unproven, including small cell lung cancer, prostate cancer, soft-tissue sarcoma and gastric cancer. Continuation of therapy is medically necessary for an approved indication when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Aetna · Identified Aug 12, 2026Medium impact
Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)
Aetna considers optical coherence tomography and microelastography experimental, investigational, or unproven for the listed intra-operative uses because their effectiveness has not been established. These uses include assessment of lymph nodes or tumor margins in breast conserving surgery, differentiation of pancreatic neoplastic lesions, differentiation of normal and diseased thyroid and parathyroid tissues, and solid tumor surgery including optical biopsy of lymph nodes and real-time determination of surgical margins. The policy lists CPT codes and ICD-10 codes as not covered for the indications it names.
Aetna · Identified Aug 12, 2026Medium impact
Barrett's Esophagus (CPB 0728, reviewed 2025-11-25)
Aetna considers radiofrequency ablation medically necessary for Barrett's esophagus with low-grade dysplasia confirmed by histology on 2 or more endoscopies performed 3 or more months apart. For Barrett's esophagus with high-grade dysplasia by biopsy, endoscopic mucosal resection, esophagectomy, fundoplication, photodynamic therapy and radiofrequency ablation are considered medically necessary. Argon plasma coagulation, cryotherapy or cryoablation, laser therapy, chemoradiation therapy, gastrectomy, multi-polar electro-coagulation and ultrasonic therapy are considered experimental, investigational or unproven for Barrett's esophagus.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus
Photodynamic therapy may be considered medically necessary for palliative treatment of obstructing esophageal cancer, palliative treatment of obstructing endobronchial lesions, early-stage non-small-cell lung cancer in individuals ineligible for surgery and radiotherapy, high-grade dysplasia in Barrett esophagus, and palliative treatment of unresectable cholangiocarcinoma when used with stenting. Other oncologic applications, including Barrett esophagus without high-grade dysplasia, are investigational. The policy history records a 09/12/2025 description update, with policy guidelines updated regarding focal therapy.
Independence Blue Cross · Effective Jul 9, 2025Low impact
07.00.10j, Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
Independence Blue Cross reissued PDT policy 07.00.10j on 07/09/2025 with no substantive changes to coverage criteria. Three CPT codes (96567, 96573, 96999) were added and four ICD-10 diagnosis codes (C23, D13.0, D37.8, D37.9) were removed. The policy maintains coverage for PDT using porfimer sodium for Barrett's esophagus, esophageal cancer, cholangiocarcinoma, endobronchial lung cancer, and specific skin conditions.
Independence Blue Cross · Identified Jun 19, 2026Low impact
MA07.030c, Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
This is an annual policy reissue with no substantive changes to coverage criteria for Photodynamic Therapy using Porfimer Sodium (Photofrin®). The policy was reissued on 07/09/2025 in accordance with Independence Blue Cross's standard annual review process. No updates to covered indications, billing codes, or medical necessity criteria have been made.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C15.3?

There are 37 tracked policy changes affecting code C15.3, including updates from Independence Blue Cross, Health Net, Excellus BlueCross BlueShield. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C15.3?

Payers that have issued tracked updates for code C15.3 include: Independence Blue Cross, Health Net, Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code C15.3 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C15.3. 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 C15.3?

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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11.03.18, Endoscopic Submucosal Dissection (ESD)

08.02.23, Tislelizumab-jsgr (Tevimbra®)

21-139 Medical Policies - 4th Quarter 2020

21-141 Medical Policies - 4th Quarter 2020

21-142 Medical Policies - 4th Quarter 2020

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

08.02.23b, Tislelizumab-jsgr (Tevimbra®)

Photodynamic Therapy for Malignant Disease 8.01.06

MA11.118, Endoscopic Submucosal Dissection (ESD)

11.03.18, Endoscopic Submucosal Dissection (ESD)

MA08.173, Tislelizumab-jsgr (Tevimbra®)

In Vivo Analysis of Gastro-Intestinal and Urothelial Lesions (CPB 0783, reviewed 2026-10-27)

Dysphagia Therapy (CPB 0625, reviewed 2026-10-21)

Amivantamab-vmjw (Rybrevant) and Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro) (CPB 0995, reviewed 2026-10-16)

Avelumab (Bavencio) (CPB 0916, reviewed 2026-10-14)

Radiofrequency Tumor Ablation (CPB 0492, reviewed 2026-10-05)

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

Liver and Other Neoplasms - Treatment Approaches (CPB 0268, reviewed 2026-09-18)

Brachytherapy (CPB 0371, reviewed 2026-05-20)

Tremelimumab-actl (Imjudo) (CPB 1019, reviewed 2026-04-27)

Trastuzumab Products (CPB 0313, reviewed 2026-06-08)

Tislelizumab-jsgr (Tevimbra) (CPB 1057, reviewed 2025-12-05)

Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2025-12-03)

Amivantamab-vmjw (Rybrevant) and Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro) (CPB 0995, reviewed 2026-08-05)

Liver and Other Neoplasms - Treatment Approaches (CPB 0268, reviewed 2026-04-16)

Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)

Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CPB 0966, reviewed 2026-05-15)

Endoscopic Ultrasonography (CPB 0446, reviewed 2026-07-22)

Photodynamic Therapy (CPB 0375, reviewed 2026-05-21)

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

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

Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)

Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)

Barrett's Esophagus (CPB 0728, reviewed 2025-11-25)

Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus

07.00.10j, Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)

MA07.030c, Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)

What insurance policy changes affect code C15.3?

Which payers have updated policy for code C15.3?

How do I get notified when code C15.3 policy changes?

Why do payers change policies for code C15.3?