ICD-10 C33 is officially defined as "Malignant neoplasm of trachea." code C33 is referenced in 21 tracked payer policy changes from Independence Blue Cross, Excellus BlueCross BlueShield, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C33 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Independence Blue Cross updated Medicare Advantage policy MA08.185a effective 11/02/2026 to align datopotamab deruxtecan-dlnk (Datroway®) coverage with FDA labeling and NCCN guidelines for non-small cell lung cancer and breast cancer. The policy adds specific ICD-10 diagnosis codes and clarifies HER2 testing requirements and clinical eligibility criteria for coverage.
Independence Blue Cross updated policy 08.02.41a for datopotamab deruxtecan-dlnk (Datroway®) effective 11/02/2026 to align with FDA labeling and NCCN guidelines. The policy adds 13 new ICD-10 diagnosis codes for lung and breast cancers and expands covered indications for the drug across invasive breast cancer, inflammatory breast cancer, unresectable or metastatic breast cancer, and non-small cell lung cancer, with HER2 testing requirements specified.
Effective June 15, 2026, autologous hematopoietic stem cell transplantation (auto-HSCT) is considered medically appropriate when the transplanting institution's selection criteria are met, the multidisciplinary team recommends treatment, and the individual meets the indication-specific criteria listed in the policy. Those criteria cover blood and plasma cancers, solid tumors, multiple sclerosis, systemic sclerosis and juvenile rheumatoid arthritis, and auto-HSCT is considered investigational for all other indications. The February 19, 2026 annual review updated the indications and criteria to align with American Society for Transplantation and Cellular Therapy guidelines.
Independence Blue Cross Medicare Advantage policy MA08.183a expands coverage for Zenocutuzumab-zbco (Bizengri®) by removing a restrictive exclusion criterion for non-small cell lung cancer and adding 16 new ICD-10 diagnosis codes for pancreatic and lung cancer indications. The policy now covers the drug for NRG1 gene fusion-positive NSCLC and pancreatic adenocarcinoma under specified medical necessity criteria.
Independence Blue Cross expanded coverage for Zenocutuzumab-zbco (Bizengri®) by removing a parenthetical exclusion from non-small cell lung cancer criteria and adding 18 new ICD-10 diagnosis codes for pancreatic and lung malignancies effective June 1, 2026. Billing teams must update systems to recognize these newly covered diagnosis codes for claim submission.
Excellus medical policy 7.02.02 sets when allogeneic hematopoietic stem cell transplantation (allo-HSCT) is considered medically appropriate. It applies when the candidate meets the transplanting institution's selection criteria, the multidisciplinary team evaluates the individual and recommends treatment, and the individual is treated for one of the listed indications. The listed indications include acute and chronic leukemias, non-Hodgkin lymphoma, myelodysplastic diseases at intermediate or high risk, sickle cell anemia under stated criteria, transfusion-dependent thalassemia, bone marrow failure syndromes, severe combined immunodeficiency, hemophagocytic disorders, several storage and leukodystrophy disorders, and certain skeletal and metabolic bone disorders. Allo-HSCT is considered investigational for all other indications. The February 19, 2026 revision simplified the criteria to the indication level, removed the investigational indications list and added HCPCS code S2142.
Independence Blue Cross has published MA08.183a, a new Medicare Advantage coverage policy for zenocutuzumab-zbco (Bizengri®), establishing medical necessity criteria for NRG1 gene fusion–positive non-small cell lung cancer and pancreatic adenocarcinoma. Billing teams must verify patients meet specific criteria including prior systemic therapy progression, LVEF ≥50%, and applicable performance status before claims are submitted. This supersedes the previous MA08.183 version and becomes effective July 28, 2025.
Independence Blue Cross published a new policy (08.02.38a, effective 07/28/2025) establishing coverage criteria for zenocutuzumab-zbco (Bizengri®) for NRG1 gene fusion-positive non-small cell lung cancer and pancreatic adenocarcinoma. The policy requires specific clinical criteria including prior systemic therapy progression, LVEF ≥50%, and ECOG performance status documentation. All other uses are considered experimental/investigational and not covered.
Aetna covers Prolia and its ten listed biosimilars, and Xgeva and its nine listed biosimilars, under commercial medical plans, and precertification is required for these denosumab products in applicable plan designs. Prolia is considered medically necessary for postmenopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, bone loss in men receiving androgen deprivation therapy for prostate cancer, bone loss in women receiving adjuvant aromatase inhibitor therapy for breast cancer, and inhibiting progression of bone erosion in rheumatoid arthritis, based on criteria such as fragility fracture history, pre-treatment T-score, pre-treatment FRAX probability, and prior therapy response or intolerance. Xgeva is considered medically necessary for multiple myeloma, bone metastases from solid tumors, giant cell tumor of bone, hypercalcemia of malignancy refractory to intravenous bisphosphonate therapy, and second-line therapy for osteopenia or osteoporosis in systemic mastocytosis, and continuation of Xgeva requires disease stability or improvement.
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'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's Clinical Policy Bulletin 0876 considers temozolomide (Temodar) injection medically necessary for brain metastases from solid tumors, metastatic or unresectable cutaneous melanoma as single agent subsequent therapy, second-line Ewing sarcoma in combination with irinotecan with or without vincristine, mycosis fungoides or Sezary syndrome with CNS involvement as single agent subsequent therapy, high-risk neuroblastoma in combination with irinotecan, dinutuximab and sargramostim or with irinotecan, naxitamab-gqgk and sargramostim, unresectable or metastatic pheochromocytoma or paraganglioma as single agent first-line therapy, relapsed or primary progressive small cell lung cancer as single agent subsequent therapy, advanced, recurrent, metastatic or inoperable uterine sarcoma as single agent subsequent therapy, and unresectable or metastatic uveal melanoma as a single agent. Aetna considers all other indications experimental, investigational or unproven, including chronic lymphocytic leukemia, diffuse large B-cell lymphoma, metastatic colorectal cancer and pituitary tumors. Continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Aetna considers coblation tonsillectomy medically necessary for peri-tonsillar abscess, recurrent middle ear infection where tonsillar hypertrophy is believed to be an exacerbating factor, recurrent or chronic tonsillar infection, and tonsillar hypertrophy leading to respiratory symptoms or airway obstruction. Aetna considers many other coblation uses experimental, investigational or unproven because their effectiveness has not been established, including coblation adenoidectomy, coblation nasal septal swell body reduction, coblation with or without gastrocnemius release for plantar fasciitis, coblation devices such as the Topaz Microdebrider for insertional Achilles tendinopathy and lateral epicondylitis, and radiofrequency to the nasal valve (Vivaer Nasal Airway Remodeling) for nasal airway obstruction. The policy lists cervical coblation nucleoplasty, coblation non-thermal volumetric tissue reduction, and several other coblation procedures as CPT codes not covered for the indications listed in the policy.
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.
This electromagnetic navigation (EN)-guided bronchoscopy policy was last reviewed June 8, 2026. EN-guided bronchoscopy is medically necessary for the pathologic diagnosis of a peripheral pulmonary nodule that cannot be reached by standard bronchoscopy or a transthoracic biopsy approach, and for transbronchial dye injection to mark pulmonary nodules before resection by thoracoscopic surgery. Cone-beam CT augmented EN-guided bronchoscopy for biopsy of indeterminate pulmonary nodules, EN-guided microwave ablation, EN bronchoscopy with non-thermal ablation (electroporation), and trans-bronchial lung cryo-biopsy to improve the diagnostic yield of digital tomosynthesis-assisted EN-guided biopsy are experimental, investigational or unproven.
Aetna's policy covers plerixafor (Mozobil or generic plerixafor) for hematopoietic stem cell mobilization when it is given after a granulocyte-colony stimulating factor such as filgrastim, after chemo-mobilization, or as part of a gene therapy protocol, and when it is not used beyond 4 consecutive days or after stem cell harvest or apheresis is complete. Continuation of therapy is considered medically necessary for members who meet the initial selection criteria. Aetna considers plerixafor experimental, investigational or unproven for all other indications, including the conditions listed in the policy such as acute leukemias, sickle cell disease, WHIM syndrome and neutropenia treatment.
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.
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's commercial medical policy sets coverage criteria for Prolia and its biosimilars and for Xgeva and its biosimilars, and precertification is required for these products in applicable plan designs. Prolia and its biosimilars are considered medically necessary for postmenopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, bone loss in men receiving androgen deprivation therapy for prostate cancer, bone loss in women receiving adjuvant aromatase inhibitor therapy for breast cancer, and inhibiting progression of bone erosion in rheumatoid arthritis. Xgeva and its biosimilars are considered medically necessary for multiple myeloma, bone metastases from a solid tumor, giant cell tumor of bone, hypercalcemia of malignancy refractory to intravenous bisphosphonate therapy, and second-line therapy for osteopenia or osteoporosis in systemic mastocytosis. All other indications are considered experimental, investigational, or unproven, and combination therapy of denosumab with intravenous bisphosphonates is also considered experimental, investigational, or unproven.
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's Microwave Thermotherapy policy (CPB 0682) was reviewed on 2026-10-26, and the source does not state what changed or give a new effective date. It covers microwave thermotherapy as medically necessary only for T1 renal lesions, medically inoperable non-small cell lung cancer lesions under 3 cm, and hepatocellular carcinoma tumors of 3 cm or less, and it lists many other uses (such as breast, pancreatic, bladder, and chronic pain indications) as experimental, investigational or unproven.
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