C43.9 Insurance Policy Changes

ICD-10 C43.9 is officially defined as "Malignant melanoma of skin, unspecified." code C43.9 is referenced in 19 tracked payer policy changes from Aetna and Blue Cross & Blue Shield of Mississippi. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C43.9 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Nov 4, 2026Medium impact
Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-10-28)
Aetna's clinical policy bulletin CPB 0892, last reviewed 2026-10-28, sets the coverage criteria for nivolumab (Opdivo), nivolumab and hyaluronidase-nvhy (Opdivo Qvantig), and nivolumab and relatlimab-rmbw (Opdualag) for Aetna commercial medical plans, including indication-by-indication initial approval criteria, continuation-of-therapy criteria, and dosing references. Precertification is required for all three products, and the site-of-care utilization management policy applies. The practice's billing team should align charge entry, precertification tracking, and documentation with the indications and continuation limits listed for each product.
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 Oct 1, 2026Medium impact
Donor Lymphocyte Infusion (CPB 0638, reviewed 2026-09-29)
Aetna considers donor lymphocyte infusion medically necessary for persons who have had a prior medically necessary allogeneic bone marrow or peripheral stem cell transplantation. Several uses are considered experimental, investigational, or unproven, including GCSF-stimulated donor lymphocyte infusions for relapsed disease, intrathecal donor lymphocyte infusion, modified donor lymphocytes, reduced-dose infusion for Epstein-Barr virus-related post-transplant lymphoproliferative disease, pre-transplant infusion of extracorporeal photochemotherapy-treated donor lymphocytes for solid organ transplant, and donor lymphocyte-derived natural killer cells for melanoma. The policy does not apply to FDA-approved chimeric antigen receptor therapy, which is addressed in CPB 0920 and CPB 0924.
Aetna · Identified Aug 18, 2026Medium impact
Total Body Photography, Dermoscopy and Other Selected Noninvasive Dermatologic Tests (CPB 0188, reviewed 2026-08-04)
Aetna considers total body photography (TBP) and dermoscopy medically necessary when used to evaluate members with a history or close family history of atypical nevi, dysplastic nevi, melanoma, or non-melanoma skin cancers. Repeat studies are not typically required more frequently than every 24 months. CPT 96904 (whole body integumentary photography) is covered when the selection criteria are met, for monitoring high-risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or a personal or family history of melanoma. Computerized TBP systems, TBP and dermoscopy for all other indications, and several other noninvasive tests are listed as experimental, investigational or unproven, including reflectance confocal microscopy, electrical impedance devices, optical coherence tomography, and the DermTech Pigmented Lesion Assay.
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
ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (CPB 0780, reviewed 2026-04-27)
Aetna considers the ADAMTS13 assay medically necessary for assessing prognosis in persons with thrombotic thrombocytopenic purpura (TTP), and for distinguishing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA, also called transplant-associated TMA) from TTP in persons with overlapping features when the test will be used to inform treatment. Aetna considers the assay experimental, investigational, or unproven for the uses it lists because of insufficient evidence, including sepsis-associated thrombotic microangiopathy, hemolytic uremic syndrome, acute myelogenous leukemia, colorectal cancer survival, COVID-19, cerebral infarction, and ADAMTS13 mutation testing for non-cirrhotic portal hypertension.
Aetna · Identified Aug 17, 2026Medium impact
Temozolomide (Temodar) Injection (CPB 0876, reviewed 2026-06-03)
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 · Identified Aug 17, 2026Medium impact
Mohs Micrographic Surgery (CPB 0383, reviewed 2026-05-28)
Aetna's Clinical Policy Bulletin 0383 considers Mohs micrographic surgery medically necessary for lesions in areas of important tissue preservation (ears, face, feet, hands, genitalia and perianal area), atypical fibroxanthoma, dermatofibrosarcoma protuberans, lesions 2 cm or larger or rapidly growing, lesions in high-recurrence areas, previously irradiated skin, recurrent or incompletely excised malignant lesions, squamous cell carcinomas with high risk of metastasis, superficial melanoma in situ and lentigo maligna in areas of important tissue preservation, tumors with aggressive histologic patterns, and tumors with ill-defined borders. Aetna considers Mohs surgery for all other indications experimental, investigational or unproven, including adenoid cystic carcinoma, nail unit melanoma, pilomatrix carcinoma, vulvar malignancies and deep cutaneous fungal infections. Mohs micrographic surgery requires a single physician to act as both surgeon and pathologist, and the Mohs CPT codes are inappropriate if either role is delegated to another physician who reports those services separately.
Aetna · Identified Aug 17, 2026Medium impact
Talimogene Laherparepvec (Imlygic) (CPB 0900, reviewed 2026-04-14)
Aetna considers talimogene laherparepvec (Imlygic) medically necessary for metastatic, unresectable, limited resectable, or borderline resectable cutaneous, subcutaneous, and nodal melanoma lesions when used as a single agent, and for palliative treatment of nodal Merkel cell carcinoma as a single agent when the member has a contraindication to or progression on anti-PD-L1 or anti-PD-1 therapy and curative surgery or radiation therapy is not feasible. Aetna considers Imlygic in combination with other immune therapies, such as ipilimumab and pembrolizumab, experimental, investigational, or unproven. Continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
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 16, 2026Medium impact
Lifileucel (Amtagvi) (CPB 1056, reviewed 2026-04-08)
Aetna Clinical Policy Bulletin 1056 covers lifileucel (Amtagvi) for commercial medical plans, and Medicare criteria are in a separate document. Aetna considers it medically necessary as a single dose for unresectable or metastatic melanoma in members 18 years and older who have already received a PD-1 blocking antibody and, if BRAF V600 mutation positive, a BRAF inhibitor with or without a MEK inhibitor. The member must not have received Amtagvi before, must not have uveal or ocular melanoma or uncontrolled brain metastases, must not have had an organ allograft (except kidney transplant) or prior cell transfer, must have adequate and stable kidney, pulmonary and cardiac function, an ECOG performance status of 0 or 1, and no clinically significant active infection. Aetna considers all other indications 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
Carbon Dioxide Laser (CPB 0427, reviewed 2026-07-08)
Aetna's clinical policy bulletin for carbon dioxide laser (CPB 0427) lists the uses it considers medically necessary: condyloma, pelvic pain associated with endometriosis, primary penile tumors (clinical stage Tis, Ta, and T1 Grade 1 to 2), refractory plantar warts, removal of actinic keratoses for members who meet CPB 0567 criteria, removal of superficial basal cell carcinomas, and fractional carbon dioxide laser for hypertrophic burn, traumatic, and surgical scars when conventional therapies have failed. Aetna considers carbon dioxide laser experimental, investigational, or unproven for a list of other indications, including hidradenitis suppurativa, male androgenetic alopecia, onychomycosis, port wine stains, stress urinary incontinence, and vaginal atrophy. Aetna considers carbon dioxide laser treatment of other actinic lesions cosmetic.
Aetna · Identified Aug 14, 2026Medium impact
Donor Lymphocyte Infusion (CPB 0638, reviewed 2025-11-12)
Aetna considers donor lymphocyte infusion (DLI) medically necessary for persons who have had a prior, medically necessary allogeneic bone marrow or peripheral stem cell transplantation. Aetna considers these uses experimental, investigational, or unproven: GCSF-stimulated DLI for relapsed disease after allogeneic hematopoietic cell transplantation, intrathecal DLI, modified donor lymphocytes (such as depleted, expanded, T-cell depleted, CAR-modified or genetically modified cells), pre-transplant infusion of extracorporeal photochemotherapy-treated donor lymphocytes to prevent graft rejection after solid organ transplantation, reduced-dose DLI for Epstein-Barr virus-related post-transplant lymphoproliferative disease, and donor lymphocyte-derived natural killer cells for melanoma. The policy does not apply to FDA-approved CAR T therapy, which involves modification of autologous lymphocytes.
Aetna · Identified Aug 14, 2026Medium impact
Dendritic Cell Immunotherapy (CPB 0377, reviewed 2026-05-26)
Aetna considers dendritic cell immunotherapy experimental, investigational, or unproven because the peer-reviewed medical literature does not support its clinical use at this time, and there is no specific CPT or HCPCS code for it. ICD-10 codes for malignant neoplasms (leukemia, lymphoma, melanoma and solid tumors) and for melanoma in situ are listed as not covered for the indications in this bulletin. Current evidence is described as anecdotal, and randomized trials are needed to establish the appropriate antigen, adjuvant, dose, route and schedule.
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.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Somatic Genetic Testing To Select Individuals with Melanoma or Glioma for Targeted Therapy (BRAF)
Testing for BRAF V600 variants in individuals with unresectable or metastatic melanoma, or with resected stage III melanoma, may be considered medically necessary to select individuals for FDA-approved BRAF or MEK inhibitors, using tissue or liquid biopsy. Testing for BRAF V600E variants in individuals with glioma may be considered medically necessary to select individuals for treatment with dabrafenib in combination with trametinib. Testing for NTRK gene fusions in individuals with unresectable or metastatic melanoma, or with glioma, may be considered medically necessary to select individuals for treatment with FDA-approved kinase inhibitors.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C43.9?

There are 19 tracked policy changes affecting code C43.9, including updates from Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C43.9?

Payers that have issued tracked updates for code C43.9 include: Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code C43.9 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C43.9. 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 C43.9?

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.

All billing codes J3590 C9399 J3490 99215 99213 99202

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Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-10-28)

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

Donor Lymphocyte Infusion (CPB 0638, reviewed 2026-09-29)

Total Body Photography, Dermoscopy and Other Selected Noninvasive Dermatologic Tests (CPB 0188, reviewed 2026-08-04)

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

ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (CPB 0780, reviewed 2026-04-27)

Temozolomide (Temodar) Injection (CPB 0876, reviewed 2026-06-03)

Mohs Micrographic Surgery (CPB 0383, reviewed 2026-05-28)

Talimogene Laherparepvec (Imlygic) (CPB 0900, reviewed 2026-04-14)

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

Lifileucel (Amtagvi) (CPB 1056, reviewed 2026-04-08)

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

Carbon Dioxide Laser (CPB 0427, reviewed 2026-07-08)

Donor Lymphocyte Infusion (CPB 0638, reviewed 2025-11-12)

Dendritic Cell Immunotherapy (CPB 0377, reviewed 2026-05-26)

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)

Somatic Genetic Testing To Select Individuals with Melanoma or Glioma for Targeted Therapy (BRAF)

What insurance policy changes affect code C43.9?

Which payers have updated policy for code C43.9?

How do I get notified when code C43.9 policy changes?

Why do payers change policies for code C43.9?