C54.9 Insurance Policy Changes

ICD-10 C54.9 is officially defined as "Malignant neoplasm of corpus uteri, unspecified." code C54.9 is referenced in 18 tracked payer policy changes from Independence Blue Cross, Blue Cross Blue Shield of North Dakota, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C54.9 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Independence Blue Cross · Effective Dec 29, 2025High impact
08.01.33l, Leuprolide (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)
Independence Blue Cross updated Leuprolide policy 08.01.33l to version 08.01.33n, adding coverage for uterine neoplasms, revising prostate cancer and head/neck cancer criteria per NCCN guidelines, and introducing Camcevi ETM 21 mg (3-month formulation). Specific ICD-10 codes for inflammatory breast cancer and uterine malignancies were added or modified with different coverage rules by formulation. The preferred product designation remains leuprolide acetate (Eligard/Lupron Depot J9217) for prostate cancer and salivary gland tumors, with nonpreferred products (Camcevi, Camcevi ETM, Lupron Depot J1950) covered only for current/prior users or those with contraindications/intolerances.
Blue Cross Blue Shield of North Dakota · Identified Jun 19, 2026High impact
Pharmacy Policy Updates
Blue Cross Blue Shield of North Dakota revised many Commercial prior authorization drug policies, with revisions effective April 14, 2026, including oncology drugs such as Adcetris, Keytruda IV, Keytruda SQ, Opdivo IV, Opdivo SQ, Darzalex IV and Trodelvy. The same notice lists Commercial post service claim edit policy revisions effective March 1, 2026 for Aranesp, Epoetin alfa and Mircera, and Commercial medical drug coding updates effective April 1, 2026 with new, removed and changed HCPCS codes.
Blue Cross Blue Shield of North Dakota · Effective Mar 17, 2026Medium impact
Pharmacy Policies Available Online
Commercial prior authorization medical drug policies have revisions effective March 17, 2026, with many policies adding the Appendix A NQTL Factor Checklist, showing the number of days allowed for authorization durations, and replacing 'coverage' with 'prior authorization validity' in the initial and renewal criteria. Clinical updates include Eylea HD for macular edema following retinal vein occlusion, Breyanzi for relapsed or refractory marginal zone lymphoma, and new appendiceal neoplasm and cancer indications with ICD-10 codes D37.3 and Z85.038. Commercial post service claim edit policies for Trogarzo have revisions effective Feb. 1, 2026.
Independence Blue Cross · Effective Dec 29, 2025Medium impact
MA08.083l, Leuprolide (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)
Independence Blue Cross updated MA08.083l to MA08.083n effective 12/29/2025, adding coverage for uterine neoplasms, revising prostate cancer and head/neck cancer criteria per NCCN guidelines, adding the new Camcevi ETM 21 mg 3-month formulation, and modifying ICD-10 code coverage to specify laterality for breast inflammatory neoplasms. The preferred product designation remains leuprolide acetate (Eligard and Lupron Depot 7.5 mg, J9217) for prostate cancer and salivary gland tumors.
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 8, 2026Medium impact
Docetaxel (CPB 0956, reviewed 2026-10-05)
For commercial medical plans, docetaxel (Beizray, Docivyx, Taxotere, or generic docetaxel) is considered medically necessary for the listed cancer indications, including breast cancer, non-small cell lung cancer, prostate cancer, gastric cancer, head and neck cancer, ovarian cancer, small cell lung cancer, and soft tissue sarcoma. Breast cancer requires the disease-status criteria stated in the policy, and continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen. All other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Trabectedin (Yondelis) (CPB 0903, reviewed 2026-01-13)
Aetna covers trabectedin (Yondelis) for commercial medical plans when the criteria for the listed sarcoma indications are met. Covered indications include advanced, recurrent/metastatic or inoperable leiomyosarcoma (first-line in combination with doxorubicin, or second-line or later as a single agent), certain soft tissue sarcomas, pleomorphic rhabdomyosarcoma, solitary fibrous tumor, dedifferentiated liposarcoma and epithelioid hemangioendothelioma. Continuation of trabectedin is medically necessary for a listed indication while there is no evidence of unacceptable toxicity or disease progression on the current regimen, and all other indications are considered experimental, investigational or unproven. This is dated 2026-01-13, so check current applicability before acting.
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
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 16, 2026Medium impact
Fibroid Treatment (CPB 0304, reviewed 2026-04-17)
Aetna considers radiofrequency ablation or transcatheter uterine artery embolization medically necessary as an alternative to hysterectomy or myomectomy for uterine fibroids when the member has persistent symptoms directly attributed to the fibroids, such as excessive menstrual bleeding, bulk-related pelvic pain, pressure or discomfort, urinary symptoms from compression of the ureter or bladder, or dyspareunia. Aetna considers myomectomy or hysterectomy using power morcellation experimental, investigational, or unproven, except in women without known or strongly suspected uterine cancer who meet the listed exception criteria, such as premenopausal women who wish to maintain fertility and have no risk factors for uterine sarcoma. Aetna also considers cryomyolysis, cryotherapy, electrical ablation, interstitial thermotherapy, laparoscopic uterine artery occlusion, lasers, focused ultrasound ablation, acupuncture, and other uses of transcatheter uterine artery embolization experimental, investigational, or unproven.
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 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
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 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
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
Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)
Aetna considers albumin-bound paclitaxel (Abraxane or generic albumin-bound paclitaxel) medically necessary for the cancers listed in its initial approval criteria, including Kaposi sarcoma, breast cancer, cutaneous melanoma, endometrial carcinoma, ovarian, fallopian tube and primary peritoneal cancer, biliary tract cancers, non-small cell lung cancer, pancreatic adenocarcinoma, small bowel adenocarcinoma, uveal melanoma, ampullary adenocarcinoma, cervical cancer, bladder cancer and vaginal cancer, when each cancer's stated criteria are met. All other indications are considered experimental, investigational, or unproven, including small cell lung cancer, prostate cancer, soft-tissue sarcoma and gastric cancer. Continuation of therapy is medically necessary for an approved indication when there is no evidence of unacceptable toxicity or disease progression on the current regimen.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C54.9?

There are 18 tracked policy changes affecting code C54.9, including updates from Independence Blue Cross, Blue Cross Blue Shield of North Dakota, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C54.9?

Payers that have issued tracked updates for code C54.9 include: Independence Blue Cross, Blue Cross Blue Shield of North Dakota, Aetna.

How do I get notified when code C54.9 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C54.9. 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 C54.9?

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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08.01.33l, Leuprolide (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)

Pharmacy Policy Updates

Pharmacy Policies Available Online

MA08.083l, Leuprolide (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)

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

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

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

Trabectedin (Yondelis) (CPB 0903, reviewed 2026-01-13)

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

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

Fibroid Treatment (CPB 0304, reviewed 2026-04-17)

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

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

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

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

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

Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)

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

What insurance policy changes affect code C54.9?

Which payers have updated policy for code C54.9?

How do I get notified when code C54.9 policy changes?

Why do payers change policies for code C54.9?