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C50.011

PAYER POLICY CHANGES

C50.011 Insurance Policy Changes

ICD-10 C50.011 is officially defined as "Malignant neoplasm of nipple and areola, right female breast." code C50.011 is referenced in 50 tracked payer policy changes from Healthfirst, Independence Blue Cross, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C50.011 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Healthfirst · Effective Apr 1, 2026High impact
NYS Medicaid Breast Cancer Selective Program Reimbursement Policy
Healthfirst's NYS Medicaid Breast Cancer Selective Program policy (PO-RE-168v1) requires prior authorization for all breast cancer surgical procedures under the program, and those procedures must be performed at NYS-approved facilities. Services rendered at restricted facilities are not eligible for reimbursement, and authorization requests listing a restricted facility will be denied. The policy applies only when a qualifying diagnosis code from Appendix A is linked to a qualifying procedure code, and Appendix A states the Medicaid breast cancer service exclusion is effective April 1, 2025.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
MA08.185a, Datopotamab deruxtecan (Datroway®)
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 · Effective Nov 2, 2026Medium impact
MA08.129c, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)
Independence Blue Cross updated Medicare Advantage policy MA08.129c effective 11/02/2026 to align with FDA labeling for Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf). The policy added 38 specific ICD-10 breast cancer diagnosis codes (C50.011 through C50.922 and C50.A1–C50.A2) to the list of covered diagnoses. Coverage remains conditioned on HER2-positive status confirmed by FDA-approved diagnostic testing, specific LVEF thresholds, and one of three treatment settings (neoadjuvant, adjuvant, or metastatic with docetaxel).
Independence Blue Cross · Effective Nov 2, 2026Medium impact
08.02.41a, Datopotamab deruxtecan (Datroway®)
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.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
08.01.72c, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)
Independence Blue Cross updated its commercial medical policy for Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf, HCPCS J9316) to match FDA labeling, and the policy text states it became effective November 2, 2026, which has already passed. It adds 38 breast cancer ICD-10 codes (C50 series) to the list of diagnoses the policy covers, and it limits coverage to listed HER2-positive breast cancer uses with set heart function (LVEF) thresholds and confirmed HER2 test results.
Independence Blue Cross · Effective Oct 1, 2026Medium impact
MA05.033f, External Breast Prostheses
Independence Blue Cross updated MA05.033f to reflect HCPCS code changes effective 10/01/2026 for external breast prostheses coverage under Medicare Advantage. The policy clarifies that L8030 and L8031 (silicone prostheses) and L8035 (custom prostheses) are covered with specific medical necessity criteria, while L8031 (integral adhesive) and L8035 (custom-fabricated) remain not medically necessary. Billing teams must ensure claims align with these coverage determinations and lifetime replacement limits.
Excellus BlueCross BlueShield · Effective Apr 16, 2026Medium impact
Germline Genetic Testing for Hereditary Cancers 2.02.60
Excellus BlueCross BlueShield policy 2.02.60 considers germline genetic testing for hereditary cancer medically appropriate in listed circumstances, including when a blood relative has a known pathogenic or likely pathogenic variant, when a pathogenic or likely pathogenic variant is found on tumor genomic testing, when results aid systemic therapy or surgical decisions, and when individuals meet specific criteria for breast, ovarian, pancreatic, prostate, colorectal, Cowden syndrome, Li-Fraumeni syndrome, hereditary diffuse gastric cancer or familial medullary thyroid carcinoma. Multigene panel testing is considered medically appropriate when an individual meets Policy Statement I, except Policy Statements I.A, I.D and I.G.9. The current effective date is April 16, 2026, and the annual update kept the policy intent unchanged.
Excellus BlueCross BlueShield · Effective Feb 19, 2026Medium impact
Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT) 7.02.02
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.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2025Medium impact
Digital Breast Tomosynthesis
Screening digital breast tomosynthesis (CPT 77063) is covered once per calendar year as an alternative to standard 2D mammography for women beginning at age 35, as part of the Healthy You! Wellness benefit, effective 01/01/2018. Digital breast tomosynthesis may be considered medically necessary as an alternative to standard 2D mammography for further imaging when used for breast cancer diagnostic purposes. Already effective 2025-10-01: ICD-10 diagnosis codes C50.A0, C50.A1 and C50.A2 for malignant neoplasm of breast were added to the code reference.
Aetna · Identified Nov 4, 2026Medium impact
Sacituzumab Govitecan-hziy (Trodelvy) (CPB 0971, reviewed 2026-10-29)
Aetna's commercial policy for Trodelvy (sacituzumab govitecan-hziy) was reviewed on 10/29/2026. Its breast cancer criteria include two first-line triple-negative uses that the FDA approved on June 24, 2026: Trodelvy as a single agent, and Trodelvy with pembrolizumab for PD-L1 positive disease (CPS 10 or higher). The source gives no separate effective date for Aetna's change, and precertification is still required.
Aetna · Identified Oct 25, 2026Medium impact
Breast Reconstructive Surgery (CPB 0185, reviewed 2026-10-20)
Aetna's Clinical Policy Bulletin 0185 on breast reconstructive surgery, last reviewed 10/20/2026, sets out the reconstructive procedures and acellular dermal matrices Aetna considers medically necessary when criteria are met, such as after a medically necessary mastectomy or lumpectomy that results in a significant deformity. It lists procedures considered experimental, investigational or unproven, and it states that breast reconstructive surgery is cosmetic for all other indications not listed. The policy also lists the CPT, HCPCS and ICD-10 codes it covers and the codes it does not cover.
Aetna · Identified Oct 18, 2026Medium impact
Gonadotropin-Releasing Hormone Analogs and Antagonists (CPB 0501, reviewed 2026-10-14)
Aetna considers gonadotropin-releasing hormone (GnRH) analogs and antagonists medically necessary for commercial plan members only for the specific indications listed for each drug, including leuprolide, goserelin, histrelin, triptorelin, degarelix, cetrorelix and ganirelix, and treats all other indications as experimental, investigational or unproven. Each drug has separate criteria for initial approval and for continuation of therapy, and continuation for prostate cancer requires clinical benefit such as serum testosterone less than 50 ng/dL and no unacceptable toxicity. Precertification is required for the prostate cancer indication, and gender dysphoria treatment for members under 18 must be prescribed by or in consultation with a provider specialized in the care of transgender youth who has collaborated care with a mental health provider.
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 5, 2026Medium impact
Mammography (CPB 0584, reviewed 2026-09-10)
Annual screening mammography is medically necessary for women aged 40 and older as a preventive service, and for women under 40 who are judged to be at high risk, such as BRCA1 or BRCA2 mutation carriers. Diagnostic mammography is covered for members with signs or symptoms of breast disease or a history of breast cancer, whether or not they have preventive benefits. AI-based mammography, contrast-enhanced mammography for members who do not meet the medical necessity criteria, and screening mammography in men outside the listed 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 Sep 30, 2026Medium impact
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CPB 0966, reviewed 2026-09-17)
Aetna Clinical Policy Bulletin 0966 covers fam-trastuzumab deruxtecan-nxki (Enhertu) for commercial medical plans, and precertification is required of all Aetna participating providers and members in applicable plan designs. Aetna considers Enhertu medically necessary for breast cancer, biliary tract cancer, esophageal, gastric or gastroesophageal junction adenocarcinoma, HER2-mutant non-small cell lung cancer, and HER2-positive (IHC 3+ or 2+) solid tumors when the stated criteria are met, and considers it experimental, investigational or unproven for all other indications. Continuation of therapy is considered medically necessary on reauthorization when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Aetna · Identified Sep 30, 2026Medium impact
Denosumab (CPB 0804, reviewed 2026-08-21)
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 · Identified Aug 19, 2026Medium impact
Breast Transillumination, Electrical Impedance Scanning (EIS), and Elastography (CPB 0386, reviewed 2026-05-26)
The policy history lists an original effective date of 02/02/2000 and a last review of 05/26/2026, and no change is described. Aetna considers these procedures experimental, investigational, or unproven because the effectiveness of these approaches has not been established: breast elastography by any method (ultrasound or magnetic resonance); combined shear-wave elastography with ultrasonography for detection of breast cancer; electrical impedance scanning (EIS) of the breast for distinguishing benign from malignant breast lesions; non-elastographic quantitative ultrasound tissue characterization for screening and diagnosis of breast cancer and for all other indications; optical coherence micro-elastography for identifying malignant tissue and lymph node involvement during breast-conserving surgery; opto-acoustic imaging of relative blood oxygen saturation and total hemoglobin for diagnosis of breast cancer; tactile breast imaging by computer-aided tactile sensors (such as BEXA and SureTouch Mobile Pressure Mapping System); and transillumination (optical imaging, light scanning or diaphanography) for detection of breast cancer. Breast transilluminators have not been proven to be an acceptable alternative to conventional mammography.
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 19, 2026Medium impact
Magnetic Resonance Imaging (MRI) of the Breast (CPB 0105, reviewed 2026-08-06)
Aetna considers breast MRI medically necessary for members who had a recent (within the past year) conventional mammogram and/or breast sonogram, when MRI may affect clinical management. Covered circumstances include detecting local tumor recurrence after mastectomy and breast reconstruction with an implant, assessing residual cancer after an incomplete lumpectomy, and adjunct screening to mammography for women at high genetic risk or with a lifetime breast cancer risk of 20 to 25 percent or more. Breast MRI is considered experimental, investigational or unproven for listed uses such as screening women with average breast cancer risk, evaluating BI-RADS 4 or 5 lesions found on mammogram or ultrasound, and screening women with dense breasts who are asymptomatic and have no additional risk factors. Computer-aided detection is considered integral to breast MRI and is not separately reimbursed.
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
Testosterone Enanthate Injection (CPB 1015, reviewed 2026-07-17)
Aetna's clinical policy for intramuscular testosterone enanthate injection (generic Delatestryl) covers it for commercial medical plans when it is medically necessary for hormone-responsive breast cancer in a premenopausal member who has benefited from oophorectomy, delayed puberty, gender dysphoria when prescribed for gender-affirming care, inoperable metastatic breast cancer in a member 1 to 5 years postmenopausal with an incomplete response to other therapy, or primary or hypogonadotropic hypogonadism with at least two confirmed low morning testosterone levels before therapy. Aetna considers age-related or late-onset hypogonadism, female sexual dysfunction or hypoactive sexual desire disorder, heart failure, and improvement of cognitive function in aging men experimental, investigational, or unproven. The brand Delatestryl has been discontinued in the U.S., and an FDA-approved generic equivalent is available.
Aetna · Identified Aug 18, 2026Medium impact
Mammography (CPB 0584, reviewed 2025-09-09)
Aetna considers annual screening mammography medically necessary as a preventive service for women aged 40 and older, and for women under 40 who are judged to be at high risk, such as BRCA1 or BRCA2 mutation carriers and women meeting the other listed risk criteria. Diagnostic mammography is covered for members with signs or symptoms of breast disease or a history of breast cancer, regardless of whether the member has preventive benefits. Digital mammography and digital breast tomosynthesis are acceptable alternatives to film and standard 2D mammography, computer-aided detection is a medically necessary adjunct, and contrast-enhanced mammography is covered only for high-risk members who meet breast MRI criteria but have a documented contraindication, intolerance, or lack of access.
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
Hematopoietic Cell Transplantation for Breast Cancer (CPB 0507, reviewed 2026-08-06)
Aetna considers autologous, tandem and allogeneic hematopoietic cell transplantation for breast cancer experimental, investigational or unproven, because their effectiveness for this indication has not been established. Aetna will cover these transplants when they are performed in a clinical trial sponsored or authorized by the National Cancer Institute (NCI) or the Federal Food and Drug Administration (FDA), and will continue to cover them off-trial when state mandates or other requirements dictate. Four randomized controlled clinical trials showed that autologous hematopoietic cell transplantation was either similar to or more harmful than standard-dose chemotherapy.
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 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 17, 2026Medium impact
Interstitial Laser Therapy (CPB 0781, reviewed 2025-08-05)
Aetna considers interstitial laser therapy medically necessary for refractory epilepsy when the criteria in CPB 0394 - Epilepsy Surgery are met. It also considers it medically necessary for persons with recurrent brain metastases, recurrent glioblastoma, or radiation necrosis who are poor surgical candidates for craniotomy and resection, where open surgery presents prohibitive surgical risk or the tumor is located at a surgically inaccessible site. Aetna considers interstitial laser therapy experimental, investigational, or unproven for many other indications, including breast tumors, liver metastases, lung cancer, prostate cancer, pancreatic cancer, thyroid nodules, tremor disorders and chronic intractable non-malignant pain.
Aetna · Identified Aug 16, 2026Medium impact
Lurbinectedin (Zepzelca) (CPB 0978, reviewed 2026-03-11)
Aetna considers lurbinectedin (Zepzelca) medically necessary for small cell lung cancer in these regimens: as a single agent for subsequent treatment after relapse, primary progressive disease, or metastatic disease that progressed on or after platinum-based chemotherapy; or in combination with atezolizumab or atezolizumab and hyaluronidase-tqjs as maintenance treatment for extensive stage disease when there is no progression after first-line induction with atezolizumab or atezolizumab and hyaluronidase-tqjs, carboplatin and etoposide. Aetna considers lurbinectedin experimental, investigational, or unproven for breast cancer, endometrial cancer, macular edema, neuroendocrine carcinoma, non-small cell lung cancer and ovarian cancer.
Aetna · Identified Aug 16, 2026Medium impact
External Breast Prosthesis (CPB 0097, reviewed 2026-01-15)
External breast prostheses are medically necessary following a medically necessary mastectomy or lumpectomy and for persons with gender dysphoria, with up to six breast prosthesis bras initially after a medically necessary mastectomy and up to six bra replacements every 12 months. One breast prosthesis per side is covered for the useful lifetime of the prosthesis, two prostheses (one per side) are covered for bilateral mastectomy or gender dysphoria, and one replacement silicone breast prosthesis is covered every 24 months. A breast prosthesis with integrated adhesive, a custom-fabricated prosthesis compared with a pre-fabricated silicone prosthesis, a prosthesis for developmental breast asymmetry, and more than one external breast prosthesis are considered not medically necessary.
Aetna · Identified Aug 16, 2026Medium impact
Margetuximab-cmkb (Margenza) (CPB 0985, reviewed 2026-05-27)
Aetna requires precertification for Margenza (margetuximab-cmkb) for participating providers and members in applicable plan designs. Aetna considers Margenza medically necessary for HER2-positive breast cancer with no response to preoperative systemic therapy, or for HER2-positive recurrent unresectable or metastatic breast cancer, when given with chemotherapy to members who have received two or more prior regimens. Continuation is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen, and all other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 16, 2026Medium impact
Sacituzumab Govitecan-hziy (Trodelvy) (CPB 0971, reviewed 2026-04-24)
Aetna requires precertification for Trodelvy (sacituzumab govitecan-hziy) for participating providers and members in applicable plan designs. Aetna considers Trodelvy medically necessary for HER2-negative recurrent unresectable or metastatic breast cancer, or disease with no response to preoperative systemic therapy, when specific prior-treatment criteria are met, and for urothelial carcinoma as a single agent after platinum-containing chemotherapy and a PD-1 or PD-L1 inhibitor. Continuation is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen, and all other indications are considered 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
Ixabepilone (Ixempra) (CPB 0869, reviewed 2026-04-07)
Aetna covers ixabepilone (Ixempra) for commercial members with breast cancer that meets one of its criteria: HER2-negative locally advanced, recurrent unresectable or metastatic disease as a single agent; HER2-positive recurrent unresectable or metastatic disease with trastuzumab as fourth line therapy and beyond; or metastatic or locally advanced disease in combination with capecitabine after resistance to an anthracycline and a taxane. Continued use is covered when there is no evidence of unacceptable toxicity or disease progression, and use beyond 3 months (12 weeks) is covered for stable disease with tumor size within 25 % of baseline. Ixabepilone is not medically necessary after a severe (CTC grade 3/4) hypersensitivity reaction to medications formulated with Cremophor EL or its derivatives, and all other indications, including cervical, colorectal, endometrial, gastric, lung, ovarian, pancreatic, prostate and uterine cancers, are considered experimental, investigational or unproven.
Aetna · Identified Aug 15, 2026Medium impact
Radium Ra 223 Dichloride (Xofigo) (CPB 0874, reviewed 2025-12-22)
Aetna considers a total of 6 injections of radium Ra 223 dichloride (Xofigo) medically necessary for treatment of bone metastases in members with castration-resistant prostate cancer when the criteria are met, and for subsequent treatment of osteosarcoma when the member has previously tried at least 2 systemic therapies. Aetna considers more than one course (a total of 6 injections) experimental, investigational, or unproven because the safety and efficacy of more than one course has not been established. The policy was last reviewed 12/22/2025. Its policy history lists an effective date of 10/17/2013 and a next review date of 10/22/2026.
Aetna · Identified Aug 15, 2026Medium impact
Quantitative Sensory Testing Methods (CPB 0357, reviewed 2026-05-22)
Quantitative sensory testing (QST), current perception threshold (CPT) testing, voltage-actuated sensory nerve conduction threshold (VsNCT) testing, and quantitative thermal testing for early diagnosis of leprosy are considered experimental, investigational, or unproven for the uses listed in this policy, because their effectiveness or clinical value has not been established. Listed uses include evaluating fibromyalgia pain, chronic itch, chronic pelvic pain, and shoulder pain, and diagnosing restless legs syndrome and small fiber neuropathy in postural orthostatic tachycardia syndrome. CPT codes 0106T through 0110T and HCPCS code G0255 are not covered for the listed indications.
Aetna · Identified Aug 15, 2026Medium impact
Gonadotropin-Releasing Hormone Analogs and Antagonists (CPB 0501, reviewed 2026-07-10)
Aetna covers gonadotropin-releasing hormone (GnRH) analogs and antagonists under its commercial medical plans for the indications the policy lists, including prostate cancer, breast cancer, ovarian cancer, central precocious puberty, endometriosis, uterine leiomyomata (fibroids), and ovulation induction or assisted reproductive technology. The policy also sets criteria for gender dysphoria treatment, including pubertal suppression in adolescents and gender transition, and for continuation of therapy. Aetna considers all other indications experimental, investigational, or unproven.
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
Breast Ductal Lavage and Fiberoptic Ductoscopy (CPB 0517, reviewed 2026-08-05)
Aetna considers breast ductal lavage medically necessary as an alternative to aspiration for diagnosing non-lactational sporadic nipple discharge when a direct nipple aspirate yields too little cellular material for adequate cytological analysis. Fiberoptic ductoscopy combined with cytology testing is medically necessary for diagnosing intra-ductal lesions in women with non-lactational sporadic nipple discharge, and as a guide for resection of known breast intra-ductal cancer. Breast ductal lavage for breast cancer screening, breast cancer risk assessment, or any other indication not listed as medically necessary, ductal endoscopy combined with lavage in the contralateral breast of women with ipsilateral breast cancer, fiberoptic ductoscopy with the Acueity System for breast cancer screening, methylation analysis of ductal lavage samples for breast cancer risk, and miRNA analysis of breast ductal fluid for detecting breast cancer are considered experimental, investigational or unproven.
Aetna · Identified Aug 14, 2026Medium impact
Breast Implant Removal (CPB 0142, reviewed 2026-03-19)
Aetna considers breast implant removal medically necessary for members who had cosmetic augmentation or breast reconstruction after a medically necessary mastectomy and who meet at least one listed criterion. The criteria include breast cancer in the implanted or contralateral breast where implant removal is necessary to excise the cancer, breast implant-associated anaplastic large cell lymphoma, implant extrusion through the skin, recurrent infections, Baker Class IV contracture associated with severe pain, severe contracture that interferes with mammography, intra- or extra-capsular rupture of silicone gel-filled implants, cutaneous hypersensitivity-like reactions that failed conventional treatments, and persistent pain, lumps, swelling or asymmetry in textured implants after the surgical incision has fully healed. Requests for removal for Baker Class III contracture that does not follow a medically necessary mastectomy, for a biopsy of a breast mass not proven to be cancerous, or for a mastectomy or lumpectomy that can be performed with the implant in place are subject to medical review. Aetna does not consider IgG testing in connection with silicone implants medically necessary, and it does not consider removal of silicone implants for autoimmune disease medically necessary unless a selection criterion is met.
Aetna · Identified Aug 14, 2026Medium impact
Breast Reconstructive Surgery (CPB 0185, reviewed 2026-04-22)
Aetna considers breast reconstructive surgery medically necessary after a medically necessary mastectomy or lumpectomy that results in a significant deformity. Medically necessary procedures include autologous fat grafting, tissue expander use, breast prosthesis implantation, mastopexy, nerve coaptation for improvement of sensation in breast reconstruction for cancer, and flap reconstructions such as DIEP, TRAM, latissimus dorsi, superior gluteal artery perforator and profunda artery perforator flaps. Alloderm, Alloderm-RTU, Cortiva, DermACELL, DermaMatrix, FlexHD, Strattice and SurgiMend are medically necessary acellular dermal matrices, while Artia, the Biodesign Nipple Reconstruction Cylinder, SimpliDerm for breast reconstruction, the body lift perforator flap technique, intraoperative hypothermia in breast reconstruction, venous super-charging and 3D volumetric imaging are considered experimental, investigational or unproven. Aetna considers breast reconstructive surgery cosmetic for all other indications not listed in the policy, and many Aetna plans specify that certain surgeries, such as post-mastectomy breast reconstruction, are not considered cosmetic.
Aetna · Identified Aug 13, 2026Medium impact
Eribulin Mesylate (Halaven) (CPB 0831, reviewed 2026-06-19)
Aetna covers eribulin mesylate (Halaven) as single-agent therapy for recurrent unresectable or metastatic breast cancer when the disease is HER2-negative, or in combination with margetuximab-cmkb or trastuzumab for HER2-positive disease as fourth line therapy and beyond. Single-agent use is also covered for dedifferentiated liposarcoma with or without concurrent well-differentiated liposarcoma, epithelioid hemangioendothelioma, extremity/body wall or head/neck, pleomorphic rhabdomyosarcoma, and retroperitoneal/intra-abdominal soft tissue sarcoma. Continuation of therapy is covered when there is no evidence of unacceptable toxicity or disease progression on the current regimen, and all other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo) (CPB 0977, reviewed 2026-04-24)
Aetna considers pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo) medically necessary for commercial medical plans in three HER2-positive breast cancer settings: neoadjuvant treatment with chemotherapy for locally advanced, inflammatory, or early-stage disease; adjuvant treatment for locally advanced or early-stage disease; and treatment of recurrent unresectable or metastatic disease or disease with no response to preoperative systemic therapy. All other indications are considered experimental, investigational, or unproven. Phesgo is for subcutaneous use in the thigh only and must not be given intravenously.
Aetna · Identified Aug 13, 2026Medium impact
Pertuzumab Products (CPB 0973, reviewed 2026-04-27)
Aetna's policy covers pertuzumab (Perjeta) and pertuzumab-dpzb (Poherdy) for the listed indications, including HER2-positive metastatic breast cancer, neoadjuvant and adjuvant early breast cancer, and HER2-positive colorectal, biliary tract, salivary gland, appendiceal, and small bowel cancers in combination with trastuzumab under the stated criteria. Precertification of both products is required of all Aetna participating providers and members in applicable plan designs, and adjuvant and neoadjuvant breast cancer treatment is approved for a total of 12 months of therapy. Gastric, lung, ovarian, pancreatic, prostate, and uterine cancers are considered experimental, investigational, or unproven.
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.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C50.011?

There are 50 tracked policy changes affecting code C50.011, including updates from Healthfirst, Independence Blue Cross, Excellus BlueCross BlueShield. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C50.011?

Payers that have issued tracked updates for code C50.011 include: Healthfirst, Independence Blue Cross, Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, Aetna.

How do I get notified when code C50.011 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C50.011. 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 C50.011?

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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NYS Medicaid Breast Cancer Selective Program Reimbursement Policy

MA08.185a, Datopotamab deruxtecan (Datroway®)

MA08.129c, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)

08.02.41a, Datopotamab deruxtecan (Datroway®)

08.01.72c, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)

MA05.033f, External Breast Prostheses

Germline Genetic Testing for Hereditary Cancers 2.02.60

Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT) 7.02.02

Digital Breast Tomosynthesis

Sacituzumab Govitecan-hziy (Trodelvy) (CPB 0971, reviewed 2026-10-29)

Breast Reconstructive Surgery (CPB 0185, reviewed 2026-10-20)

Gonadotropin-Releasing Hormone Analogs and Antagonists (CPB 0501, reviewed 2026-10-14)

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

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

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

Mammography (CPB 0584, reviewed 2026-09-10)

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

Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CPB 0966, reviewed 2026-09-17)

Denosumab (CPB 0804, reviewed 2026-08-21)

Breast Transillumination, Electrical Impedance Scanning (EIS), and Elastography (CPB 0386, reviewed 2026-05-26)

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

Magnetic Resonance Imaging (MRI) of the Breast (CPB 0105, reviewed 2026-08-06)

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

Testosterone Enanthate Injection (CPB 1015, reviewed 2026-07-17)

Mammography (CPB 0584, reviewed 2025-09-09)

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

Hematopoietic Cell Transplantation for Breast Cancer (CPB 0507, reviewed 2026-08-06)

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)

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

Interstitial Laser Therapy (CPB 0781, reviewed 2025-08-05)

Lurbinectedin (Zepzelca) (CPB 0978, reviewed 2026-03-11)

External Breast Prosthesis (CPB 0097, reviewed 2026-01-15)

Margetuximab-cmkb (Margenza) (CPB 0985, reviewed 2026-05-27)

Sacituzumab Govitecan-hziy (Trodelvy) (CPB 0971, reviewed 2026-04-24)

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

Ixabepilone (Ixempra) (CPB 0869, reviewed 2026-04-07)

Radium Ra 223 Dichloride (Xofigo) (CPB 0874, reviewed 2025-12-22)

Quantitative Sensory Testing Methods (CPB 0357, reviewed 2026-05-22)

Gonadotropin-Releasing Hormone Analogs and Antagonists (CPB 0501, reviewed 2026-07-10)

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

Breast Ductal Lavage and Fiberoptic Ductoscopy (CPB 0517, reviewed 2026-08-05)

Breast Implant Removal (CPB 0142, reviewed 2026-03-19)

Breast Reconstructive Surgery (CPB 0185, reviewed 2026-04-22)

Eribulin Mesylate (Halaven) (CPB 0831, reviewed 2026-06-19)

Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo) (CPB 0977, reviewed 2026-04-24)

Pertuzumab Products (CPB 0973, reviewed 2026-04-27)

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)

What insurance policy changes affect code C50.011?

Which payers have updated policy for code C50.011?

How do I get notified when code C50.011 policy changes?

Why do payers change policies for code C50.011?