C54.1 Insurance Policy Changes

ICD-10 C54.1 is officially defined as "Malignant neoplasm of endometrium." code C54.1 is referenced in 9 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 C54.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Oct 13, 2026Medium impact
Temsirolimus (Torisel) (CPB 0873, reviewed 2026-10-08)
Aetna's Clinical Policy Bulletin 0873 considers temsirolimus (Torisel or generic temsirolimus) medically necessary as a single agent for subsequent treatment of locally advanced, recurrent or metastatic endometrial carcinoma, for relapsed or refractory mantle cell lymphoma, and for advanced renal cell carcinoma, along with specified soft tissue sarcoma and uterine sarcoma subtypes. The covered sarcoma uses are locally advanced unresectable or metastatic perivascular epithelioid cell tumor (PEComa), recurrent angiomyolipoma or lymphangioleiomyomatosis, and rhabdomyosarcoma (maximum 12 cycles, given with cyclophosphamide and vinorelbine). Aetna considers temsirolimus experimental, investigational or unproven for all other indications, including acute lymphoblastic leukemia, breast cancer, colorectal cancer, melanoma, multiple myeloma and prostate cancer, and for endovascular treatment of below-the-knee atherosclerotic lesions.
Aetna · Identified Aug 18, 2026Medium impact
Temsirolimus (Torisel) (CPB 0873, reviewed 2025-10-09)
Aetna considers temsirolimus (Torisel or generic temsirolimus) medically necessary as a single agent for subsequent treatment of locally advanced, recurrent, or metastatic endometrial carcinoma, for relapsed or refractory mantle cell lymphoma, and for advanced renal cell carcinoma. It also considers it medically necessary for specified soft tissue sarcoma subtypes, for rhabdomyosarcoma (maximum 12 cycles, with cyclophosphamide and vinorelbine), and for subsequent treatment of advanced, recurrent/metastatic, or inoperable PEComa in uterine sarcoma. Aetna considers all other indications experimental, investigational, or unproven, and considers continuation of therapy medically necessary when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
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 14, 2026Medium impact
Endometrial Cancer Screening, Diagnosis, and Prognosis (CPB 0769, reviewed 2025-10-03)
Aetna considers endometrial biopsy medically necessary for the diagnostic evaluation of abnormal uterine bleeding in women suspected of having endometrial hyperplasia or endometrial carcinoma, and for endometrial cancer surveillance in women with Lynch syndrome. The endometrial brush (Tao brush) is an acceptable alternative to a suction curette such as the Pipelle for medically necessary sampling. Sentinel lymph node mapping is medically necessary for pathologic evaluation and surgical staging in persons with endometrial cancer and endometrial intraepithelial neoplasia (EIN), while endometrial biopsy for screening and many biomarker and genetic tests for endometrial cancer are 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
Decitabine (CPB 0868, reviewed 2026-06-10)
Aetna considers decitabine medically necessary for accelerated or blast phase myeloproliferative neoplasm, acute myeloid leukemia, blastic plasmacytoid dendritic cell neoplasm when used with venetoclax, classic Hodgkin lymphoma when used with pembrolizumab and refractory to at least three prior lines of therapy, myelodysplastic syndromes, and myelodysplastic syndrome/myeloproliferative neoplasm overlap neoplasms. Continuation of decitabine is considered medically necessary for those indications when there is no evidence of unacceptable toxicity or disease progression on the current regimen. Aetna considers decitabine experimental, investigational, or unproven for all other indications, including colon, lung, melanoma, ovarian and other solid tumors, multiple myeloma, sickle cell disease, and use in combination with azacitidine.
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
Oncologic Applications of Positron Emission Tomography (PET) Scanning
FDG-PET or FDG-PET/CT may be considered medically necessary for listed cancers when specific criteria are met, such as staging or restaging of muscle-invasive bladder cancer, Ewing sarcoma and osteosarcoma, brain cancer, lymphoma, and multiple myeloma. PET for surveillance, meaning scans performed more than 6 months after completion of cancer therapy (12 months for lymphoma) in individuals without objective signs or symptoms of recurrence, is considered investigational, and fluoroestradiol F18 PET in individuals with breast cancer is considered investigational. The medically necessary situations assume that the PET results will influence treatment decisions, and if the results will not influence treatment decisions, those situations are considered not medically necessary.
Aetna · Identified Nov 4, 2026Low impact
Microwave Thermotherapy (CPB 0682, reviewed 2026-10-26)
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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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C54.1?

There are 9 tracked policy changes affecting code C54.1, 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 C54.1?

Payers that have issued tracked updates for code C54.1 include: Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code C54.1 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C54.1. 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 C54.1?

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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Temsirolimus (Torisel) (CPB 0873, reviewed 2026-10-08)

Temsirolimus (Torisel) (CPB 0873, reviewed 2025-10-09)

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

Endometrial Cancer Screening, Diagnosis, and Prognosis (CPB 0769, reviewed 2025-10-03)

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

Decitabine (CPB 0868, reviewed 2026-06-10)

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

Oncologic Applications of Positron Emission Tomography (PET) Scanning

Microwave Thermotherapy (CPB 0682, reviewed 2026-10-26)

What insurance policy changes affect code C54.1?

Which payers have updated policy for code C54.1?

How do I get notified when code C54.1 policy changes?

Why do payers change policies for code C54.1?