What insurance policy changes affect code C16.9?

There are 18 tracked policy changes affecting code C16.9, including updates from Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C16.9?

Payers that have issued tracked updates for code C16.9 include: Aetna.

How do I get notified when code C16.9 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C16.9. 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 C16.9?

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.

PAYER POLICY CHANGES

C16.9 Insurance Policy Changes

ICD-10 C16.9 is officially defined as "Malignant neoplasm of stomach, unspecified." code C16.9 is referenced in 18 tracked payer policy changes from Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C16.9 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

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 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 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
Helicobacter Pylori Infection Testing (CPB 0177, reviewed 2026-03-20)
Aetna considers FDA-cleared carbon isotope (13C or 14C) urea breath testing and stool antigen testing (HpSA) medically necessary for active Helicobacter pylori infection in selected persons, including adults with idiopathic thrombocytopenic purpura, persons before bariatric surgery, persons before starting proton pump inhibitor therapy for dyspepsia, and persons taking long term, low-dose aspirin or initiating chronic NSAID treatment. Nucleic acid amplification for clarithromycin resistance testing is medically necessary for selecting salvage regimens for treatment-experienced individuals with persistent H. pylori infection. H. pylori serology, the AmHPR panel, IL-1B and TNFA gene polymorphism testing, and urea breath or stool antigen testing for other indications such as stroke risk, dementia risk and screening of asymptomatic persons are considered experimental, investigational or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Ado-trastuzumab Emtansine (Kadcyla) (CPB 0974, reviewed 2026-01-21)
Aetna covers ado-trastuzumab emtansine (Kadcyla) for commercial medical plans and requires precertification for it. Covered uses include HER2-positive breast cancer in the settings listed in the policy, non-small cell lung cancer with HER2 (ERBB2) mutations when the drug is used as a single agent and the member has not progressed on a HER2 targeted drug such as Enhertu, and recurrent, unresectable or metastatic HER2-positive salivary gland tumors. Aetna considers all other indications experimental, investigational, or unproven, including use together with Herceptin, Tykerb or Perjeta, HER2-negative breast cancer, gastric cancer, colorectal cancer and hepatobiliary cancers.
Aetna · Identified Aug 17, 2026Medium impact
Flow Cytometry, Ektacytometry, DNA Ploidy, and S-phase Fraction (CPB 0351, reviewed 2026-05-21)
Aetna considers flow cytometry for cell surface markers medically necessary for listed conditions, including abnormal tissue, bone marrow or blood histology suspicious for lymphoma, leukemia or myelodysplastic syndrome, multiple myeloma, paroxysmal nocturnal hemoglobinuria, primary immunodeficiencies, Sezary syndrome diagnosis, and T-cell monitoring for HIV infection and AIDS. Flow-cytometry-derived DNA ploidy or S-phase fraction is medically necessary only in localized cancers without metastatic disease, namely endometrial adenocarcinoma, gastric cancer, mediastinal neuroblastoma, medulloblastoma, ovarian carcinoma, partial hydatidiform mole, prostatic adenocarcinoma, renal cell adenocarcinoma and urinary bladder carcinoma, and only when the prognostic information will affect treatment decisions. Ektacytometry is medically necessary for red blood cell cytoskeleton and hydration disorders when red blood cell morphology does not provide a clear diagnosis. The red blood cell adhesion index for all indications, DNA ploidy or S-phase testing in breast, cervical, colorectal, non-small cell lung, small cell lung and pediatric intracranial tumors, and microfluidic flow adhesion assays for sickle cell disease are experimental, investigational or unproven.
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
Pemetrexed Products (CPB 0687, reviewed 2026-07-17)
Aetna considers pemetrexed (Alimta, Axtle, Pemfexy, Pemrydi RTU, or generic pemetrexed) medically necessary for commercial members with the listed indications: non-squamous non-small cell lung cancer, pleural and peritoneal mesothelioma, ovarian, fallopian tube and primary peritoneal cancer, cervical cancer, bladder cancer, primary CNS lymphoma, thymoma and thymic carcinoma, thyroid cancer, and vaginal cancer. Members with squamous cell non-small cell lung cancer are not eligible, and indications such as breast, colorectal, gastric, pancreatic and small cell lung cancer are experimental, investigational, or unproven. Continuation is covered when there is no unacceptable toxicity or disease progression, and use with pembrolizumab for pleural or peritoneal mesothelioma is covered for up to 24 months total.
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.

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

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

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

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)

Helicobacter Pylori Infection Testing (CPB 0177, reviewed 2026-03-20)

Ado-trastuzumab Emtansine (Kadcyla) (CPB 0974, reviewed 2026-01-21)

Flow Cytometry, Ektacytometry, DNA Ploidy, and S-phase Fraction (CPB 0351, reviewed 2026-05-21)

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)

Pemetrexed Products (CPB 0687, reviewed 2026-07-17)

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)

What insurance policy changes affect code C16.9?

Which payers have updated policy for code C16.9?

How do I get notified when code C16.9 policy changes?

Why do payers change policies for code C16.9?